Sudden cardiac arrest without successful cardiopulmonary resuscitation (CPR) is the third leading cause of death in industrialised nations1,21,2 – and a very much under-acknowledged health issue. Today, fewer than 10% of cardiac arrest patients survive in good condition. Every year about 350,000 people die in Europe after such an event. This amounts to 1,000 lives per day – every day throughout the entire year in Europe. More or less the same numbers apply for the US.2–42–42–4 Many of these lives could be saved if more lay people would immediately start with resuscitation procedures. The professional response by paramedics and physicians will take 8–12 minutes and often longer but the brain starts to die after 3–5 minutes. This is the “Time window for lay resuscitation”.5 In around 70% of cases, lay people who witness such a collapse could perform the key procedure: cardiac compressions. Lay resuscitation rates all over Europe are very different, however, starting at less than 10% in some countries and amounting to more than 80% in some parts of Norway.3
We know from multiple activities in Denmark over a 10-year period that survival rates can be tripled by increasing lay resuscitation rates from 20% to more than 50%.6 In adults, it is sufficient if lay people perform thoracic compressions in most cases since there is still oxygen in the lungs and in the blood outside the brain.7 If the Norwegian lay bystander CPR rates were applied all over Europe, we would be able to save up to 100,000 lives additionally per year in Europe2 – and more than 200,000 lives per year worldwide. For Europe, this is four to five times more lives than lost every year in road traffic accidents. And how much money do we invest to make traffic safer? With lay CPR, we would have to invest far less to have a much greater effect on survival. Anaesthesiologists across Europe and elsewhere have started to help improve the rates of bystander CPR in their respective countries.
School children education in CPR
Resuscitation is quite easy. Even children and young adults can do it successfully. In Norway, it has been mandatory to train schoolchildren in resuscitation for decades, and in that country we find the highest bystander CPR rates.3 In many countries, initiatives have now been started. The European Resuscitation Council (ERC), the American Heart Association (AHA), the German anaesthesiologists,8 national resuscitation councils, and other organisations are very active in this regard and curricula for educating schoolchildren in CPR have been developed (www.grc-org.de).
It is well known that:9
- Educating school children should start before puberty – at around 12 years of age.
- Two hours training per year is enough.
- All groups in our societies can be reached.
- School children share their CPR knowledge with their friends and family – they serve as effective CPR multipliers.
- Teachers educated by healthcare professionals can successfully teach CPR.
- Educating school children in CPR is fun – and makes for enthusiastic pupils.
- As a further social benefit, school children learn to help others.
Last year, the German anaesthesiologists together with the German Resuscitation Council were successful in convincing the delegates of the German Education Ministries to recommend CPR training for two hours per year from class seven onward in all schools nationwide. Many other countries are doing the same. In some parliaments, education of schoolchildren in CPR has been approved or is just about to be approved.
Very recently, the World Health Organization endorsed the statement on “Kids save lives” – a joint statement from the European Patient Safety Foundation, the European Resuscitation Council, the International Liaison Committee on Resuscitation and the World Federation of Societies of Anesthesiologists.10,1110,11 This statement recommends teaching school children from the age of 12 years onward for two hours per year in CPR. Anaesthesiologists – and many others – worldwide became enthusiastic about this and are helping.
October 16: “European Restart a Heart Day” – Lay resuscitation
In 2013 and upon an initiative of the European Resuscitation Council, 400 Members of the European Parliament supported the concept of having a yearly “European Restart a Heart Day”, which is on October 16 – the “World Anaesthesia Day” – every year (www.erc.edu). On that day many different multidisciplinary and multiprofessional activities have taken place in many European countries over the last two years.12 The motto of the 2014 European Restart a Heart Day was “Your hands can save a loved one's life”, and in 2015 – since the new European Resuscitation Council CPR Guidelines were published on October 15 – the motto is “Your hands can save more lives – with the new guidelines”.12
In Germany, the numbers are well known: German anaesthesiologists together with the German Resuscitation Council have reached 746 million inhabitants – i.e. each inhabitant was reached about nine times by media activities – and so far more than 200,000 inhabitants have been trained in CPR8,9,138,9,138,9,13 as part of this campaign. As a result, the bystander CPR rates in Germany – which were below 20% before 2013 – increased to 30% in 2014.14 Other countries have been similarly successful.
On October 16, 2013 and upon an initiative of the European Resuscitation Council, a 16-year-old teenager named Kea from Cologne, Germany, showed the former European Commissioner of Health, Tonio Borg, how to successfully resuscitate. Some months before, Kea had successfully resuscitated Nic. Nic was 12 years old and went into ventricular fibrillation due to cardiac abnormalities – and had to wait for more than 10 minutes for the emergency medical services.
One of the most effective ways to increase bystander CPR rates immediately is telephone CPR.15,1615,16 This means that the dispatcher tells the lay person on the phone how to successfully perform thoracic compressions (Standard Operating Procedures for telephone CPR are available at www.grc-org.de). The “number needed to treat” for telephone CPR is around seven – i.e. a dispatcher can save one additional life by performing telephone CPR seven times. Thus, if he or she does it for 10 minutes each time, it takes only 70 minutes to save one additional life. There are obviously no, or only very few, additional costs associated with this approach. In some European countries, telephone CPR is performed nationwide, and in some, it has just started.
IOM – The health arm of the US National Academy of Sciences
The Institute of Medicine (IOM) is the most important US institution for developing health policies and presents strong suggestions and recommendations. The IOM belongs to the US National Academy of Sciences and says about itself: “the IOM is the health arm of the National Academy of Sciences” (www.iom.edu). We are all familiar with one key activity from IOM from the past when initiating the campaign “To err is human”.
A few months ago, the IOM report was made public. The link to all presentations and strategic suggestions on cardiac arrest and CPR is now freely available.17 Some of the important initiatives and ideas that we have in Europe are included in this report. The headlines associated with the IOM report are:4,174,17 “Strategies to improve cardiac arrest survival - A time to act” and “Cardiac arrest kills many, often ignored”. The report mainly focuses on “Cardiac arrest can strike a seemingly healthy individual”, “Opportunities for improvement”, “Educating and engaging the public”, “Centralising the collection and distribution of data” – with national and international data bases –, “Improving delivery of care”, “Increasing the impact of research and therapies” – far less funding is granted for resuscitation research than for other diseases that are just as common, such as cancer, cardiac diseases, and strokes18 – and “Strengthening stakeholder collaboration”. The IOM report stated that “A national responsibility exists to significantly improve the likelihood of survival and favourable neurologic outcomes following a cardiac arrest”.4,174,17 Here, anaesthesiologists are specialists. Therefore, one focus is public education and educating schoolchildren in CPR, and other focuses are on CPR registries and purely basic and clinical scientific research. USA today spotted the publication of the IOM report on June 30, 2015 – “Cardiac arrest kills many, often ignored”19 –, and JAMA has published an Editorial on this.4 This confirms that we are at the forefront of a sociomedical and social movement in this area ...
“A time to act” – For anaesthesiologists
Thanks to the billions invested in roads, education, and vehicle safety, traffic accidents cause far fewer deaths today than decades ago. Now it is time to invest in safety and survival without disability related to cardiac arrest. Anaesthesiologists are already very active in this field, and we can improve this work and our visibility much more by being involved in this.
Among the things that will have the greatest benefit are nationwide CPR training for schoolchildren, telephone CPR, cardiac arrest registries and legislation that not only requires deaths by traffic accident to be registered but also mandatory registration of cardiac arrest and CPR.
Sudden cardiac arrest is one of the most important issues in health care.1,2,4,17,20,211,2,4,17,20,211,2,4,17,20,211,2,4,17,20,211,2,4,17,20,211,2,4,17,20,21 Indeed, preventing deaths by cardiac arrest and promoting CPR is a task every anaesthesiologist worldwide should get involved in! Resuscitation has always been part of anaesthesiology. Apart from prevention, the education of schoolchildren and lay CPR are the best ways of fighting it – and anaesthesiologists are the perfect educators. The message to the public is clear: successful CPR is perfectly easy; you can do it. Lay people can’t do anything wrong – the only wrong thing would be to do nothing.
Together, and with many other specialists, societies, healthcare providers, teachers and politicians, we can easily save 100,000 additional lives every year in Europe and more than 200,000 lives worldwide, meaning 548 every day, and one every 2.5 minutes.
“It takes a society to save lives” – cardiac arrest is a community issue – and anaesthesiologists can be particularly active and visible here.
Acknowledgements related to this article
Assistance with the Editorial: none.
Financial support and sponsorship: none.
Conflicts of interest: the initiatives to improve lay resuscitation in Germany, in Europe and worldwide are related to many individuals, organisations and campaigns. The main promoters of these initiatives are the European Resuscitation Council (ERC), the Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), the Berufsverband Deutscher Anästhesisten (BDA), the Deutsches Reanimationsregister, the Stiftung Deutsche Anästhesiologie, the German Resuscitation Council (GRC), many other National Resuscitation Councils in Europe, the American Heart Association (AHA), and the International Liaison Committee on Resuscitation (ILCOR). BWB is a member of the board of the European Resuscitation Council (ERC).
Comment from the editor: this editorial was checked by the editors but was not sent for external peer review. BWB is an Associate Editor of the European Journal of Anaesthesiology.
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