Community cardiopulmonary resuscitation programmes with an emphasis on high-quality lay rescuer community cardiopulmonary resuscitation and ambulatory external defibrillation use have the ability and capacity to save lives. Historically, the survival outcomes for out-of-hospital cardiac arrest in both children and adults have been quite poor, though it is improving.Reference Savastano, Kiersy and Raimondi ¹ Similarly, the incidence of lay rescuer community cardiopulmonary resuscitation has been quite low with previous estimates of 10–15%Reference Hazinski, Idris and Kerber ² , though recent estimates show some improvement – although still poor – in the 30% range.Reference McNally, Robb and Mehta ³ Several studies in the last several years have suggested that lay rescuer community cardiopulmonary resuscitation/ambulatory external defibrillation use can be increased by community education initiatives, and a concomitant increase in out-of-hospital cardiac arrest survival can be expected. A review of several of these studies is in order.

In 2009 Drezner reported the results of a retrospective analysis of high-school community cardiopulmonary resuscitation–ambulatory external defibrillation programmes across the United States of America with attention to emergency action plan implementation and the characteristics and outcomes of sudden cardiac arrest episodes in schools having these programmes.Reference Drezner, Rao and Heistand ⁴ Of the 1710 that reported the presence of community cardiopulmonary resuscitation/ambulatory external defibrillation programmes, ~2% had an episode of sudden cardiac arrest that required implementation of community cardiopulmonary resuscitation and an ambulatory external defibrillation. Incredibly, in the schools that had such an event there was a 94% incidence of lay rescuer community cardiopulmonary resuscitation. Equally interesting was the fact that in such cases there was a 64% incidence of survival. In a follow-up prospective study by Drezner of US high schools with community cardiopulmonary resuscitation/ambulatory external defibrillation programmes, it was noted that the survival for witnessed arrests associated with ventricular fibrillation was in the 90% range.Reference Drezner, Toresdal and Rao ⁵

In 2015 Nakahara reported the outcomes of over 167,000 bystander-witnessed out-of-hospital cardiac arrests of presumed cardiac origin in Japan from a Japanese registry over a 2-year period from 2005 to 2007.Reference Nakahara, Tomio and Ichikawa ⁶ He evaluated the incidence of bystander pre-hospital intervention and intact neurology survival 1 month after discharge. In this study the age-adjusted survival increased from 3 to 8% during the observation period. The reason for this increase in neurologically intact survival was attributed to the fact that during the course of this study bystander community cardiopulmonary resuscitation increased from 38 to 50%.

A study was undertaken in 2015 in North Carolina in order to ascertain the temporal changes in resuscitation performed by bystanders and first responders following state-wide initiative from 2010 to 2013 to improve resuscitation efforts.Reference Malta Hansen, Kraigholm and Pearson ⁷ The initiatives included the training of the lay public in community cardiopulmonary resuscitation/ambulatory external defibrillation use, training first responders in team-based community cardiopulmonary resuscitation/ambulatory external defibrillation use, and training dispatchers to recognise cardiac arrest and perform high-quality community cardiopulmonary resuscitation. The results showed that the administration of bystander community cardiopulmonary resuscitation and first-responder defibrillation increased from 14 to 23% from 2010 to 2013 and was accompanied by an increase in survival from 7 to almost 10%.

In 2015 Jayaram reported the survival for out-of-hospital cardiac arrest in children via the prospective Cardiac Arrest Registry to Enhance Survival study.Reference Jayaram, McNally and Tang ⁸ He assessed the hospital survival between 2005 and 2013 in children <18 years of age who had a cardiac arrest. He also looked at three different time periods over the course of the study. He found that the overall survival rate to hospital discharge was 8.2%, that infants and younger children were less likely to survive as compared with teenagers, and that there were no temporal trends in survival over the years; that is, survival rates did not improve over time.

Finally, in 2015 the results of an important Swedish study were reported by the New England Journal of Medicine.Reference Hasselqvist-Ax, Riva and Herlitz ⁹ Three million people in Sweden have been trained to do community cardiopulmonary resuscitation and it was asked whether this might increase the incidence of lay rescuer community cardiopulmonary resuscitation as well as survival outcomes. An analysis of over 30,000 out-of-hospital cardiac arrests between 1990 and 2011 was preformed in order to answer these important questions. In this study it was noted that community cardiopulmonary resuscitation performed before emergency medical services arrival resulted in a 30-day survival rate after out-of-hospital cardiac arrest that was more than twice the survival (10.5 versus 4%) with no community cardiopulmonary resuscitation before emergency medical services arrival.

The above studies support the critical importance of immediate lay rescuer community cardiopulmonary resuscitation/ambulatory external defibrillation use in order to optimise survival after cardiac arrest. These studies support the concepts of teaching community cardiopulmonary resuscitation and ambulatory external defibrillation use to the general public, of understanding how to recognise cardiac arrest, and of the willingness to intervene by performing community cardiopulmonary resuscitation. An important part of this strategy includes the concept that all students should learn community cardiopulmonary resuscitation and ambulatory external defibrillation use before graduation from high school and that all schools have a community cardiopulmonary resuscitation–ambulatory external defibrillation programme. As it has been shown that this strategy will result in improved survival outcomes for out-of-hospital cardiac arrest, one must next ask how success might be achieved in reaching these goals. That is to say, how can we best advocate for and succeed in ensuring that all schools – and all public institutions for that matter – and that all students and all citizens are properly prepared to respond to out-of-hospital cardiac arrest, including proper performance of community cardiopulmonary resuscitation.

There may be several approaches to this issue, and they are not at all mutually exclusive. Partnerships between grass roots organisations is one of the very important keys to success. In addition, education, media support, and public relations partnerships are critical to “getting the word out”. There are several examples of some very outstanding grass roots organisations that have done tremendous work in this area and who are actively pursuing strategies of education with regard to awareness, advocacy for community cardiopulmonary resuscitation and ambulatory external defibrillation education, and advocacy for implementation of community cardiopulmonary resuscitation/ambulatory external defibrillation programmes in schools and elsewhere. One of the most powerful opportunities comes when an incidence of sudden cardiac arrest or sudden cardiac death occurs in a particular community. In either case, partnerships among stakeholders and media coverage can be very helpful in delineating the importance of community cardiopulmonary resuscitation education and early intervention, so that the best likelihood of a sustained successful outcome can be realised. In our experience, the grass roots approach with a coordinated multi-faceted support is critical. This multi-faceted and multi-organisational approach will enable the concept of “CPR education for all” to actually be possible.

Legislation to provide for either mandated community cardiopulmonary resuscitation education for all students before graduation and mandated school community cardiopulmonary resuscitation–ambulatory external defibrillation programmes, or both, has recently been in the news and represents an additional strategy to achieve the goals previously described. As described in great deal earlier in this compendium, there is a rationale for this strategy, because it will certainly save lives. Currently in the United States of America, 27 states have mandates for community cardiopulmonary resuscitation education for all students, and 23 states do not have such legislation. The concept of mandatory community cardiopulmonary resuscitation education for all students is supported by the American Heart Association as well as by many other advocacy groups. There is active advocacy work in the 23 states without this legislation for the establishment of a law for mandatory community cardiopulmonary resuscitation education for students. It should be noted that, although those states with mandates are unfunded for the most part, all schools that are affected by this legislation have been able to meet the requirements of community cardiopulmonary resuscitation–ambulatory external defibrillation education with the help of the aforementioned advocacy groups who not only helped in the establishment of the legislation itself but have also been involved with the donation of time and resources in order to make this happen. Success in ‘getting the word out’ to state lawmakers can occur only with this collaboration between and among parents, students, physicians, school nurses, administrators, coaches, and – ultimately – lawmakers.

In summary, there is ample evidence to suggest that lay rescuer community cardiopulmonary resuscitation saves lives. A goal of having every US citizen learn community cardiopulmonary resuscitation and learn how to use an ambulatory external defibrillation is possible. School community cardiopulmonary resuscitation–ambulatory external defibrillation education programmes are an important first step towards achieving this goal. This concept unquestionably has been responsible for the improved outcomes associated with out-of-hospital cardiac arrest when it has occurred at schools with community cardiopulmonary resuscitation–ambulatory external defibrillation programmes. We are poised to achieve this goal but can do so only with the assistance of the multiple partners, advocacy groups, and grass roots organisations. This approach has resulted in the progress that we have experienced thus far and it will hopefully get us “to the next level”. There is much work to be done.