Abstract
Background
A school has a 1–2 % chance of having a sudden cardiac arrest (SCA) on its campus in any given year. Schools can be prepared by having automated external defibrillators (AEDs) readily accessible with staff trained in their use. The overall survival rate of SCA is less than 10 %. However, those who suffer SCA at a school that has an AED on-site have more than a 60 % chance of surviving to discharge. Currently, AEDs are not required in schools across all 50 states in the US.
Objective
Investigate the availability of AEDs in high schools across a state prior to any formal mandate and explore discrepancies among schools of varying enrollment sizes.
Methods
A 16-question survey about AED availability, accessibility, and percentage of staff trained for its use was distributed to every high school in Nebraska in July 2022.
Results
Schools with smaller enrollments were more likely to have AEDs accessible to the public ( p = 0.047), available at all events ( p = 0.0002), and over 50 % of staff trained for its use ( p = 0.00019) than schools with larger enrollments. There was no correlation between number of AEDs and enrollment (R 2 = 0.172).
Conclusions
Most high schools have automated external defibrillators (AEDs), even without statewide mandates; however, continuing efforts are needed to ensure that AEDs at all schools are accessible to the public and that staff are appropriately trained. This study highlights the need for increased advocacy and targeted resource allocation, particularly for larger schools, to ensure appropriate/adequate AED distribution and emergency preparedness across all high schools.
Highlights
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Automated external defibrillators increase survival of sudden cardiac arrest.
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AEDs are not required in schools in all 50 states in the US.
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Schools with higher enrollment are less prepared for SCA than smaller schools.
1
Introduction
The incidence of out-of-hospital sudden cardiac arrest (SCA) for children in the United States is over 23,000 per year [ ]. Survival to discharge for children following a non-traumatic SCA is estimated to be as low as 7.3 % [ ]. Timely intervention in the form of cardiac defibrillation greatly improves survival rates. For every minute that passes without intervention, survival rate decreases by 7–10 % [ ]. Patients who receive defibrillation via an automated external defibrillator (AED) within 5 min of SCA have a 35.2 % one-month survival rate, compared to 28.4 % for those who receive defibrillation longer than 10 min after SCA [ ]. Likewise, cardiac defibrillation administered by bystanders placing an AED is associated with higher survival rates (53 %) after SCA, than if defibrillation is delayed until the arrival of emergency medical services (28.6 %) [ ]. The probability of a high school having an SCA event on its campus in any given year is estimated to be between 0.8 % and 2.1 % [ , ]. A survey study that polled 1710 high schools with at least one AED found that individuals who had witnessed SCA on campus survived discharge in 64 % of cases [ ].
The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) recommend placement of an AED in every school, focusing first on high schools and every school athletic facility. In addition, emphasis is placed on training school staff to properly use an AED [ , ]. Currently, AED placement and training is not mandated in high schools across all 50 states. At the time of this study, Nebraska had no requirement for AEDs in schools, nor presence of a structured program or collaborative to ensure readiness for AED response in schools, as this was prior to Nebraska’s involvement in Project ADAM® [ , ]. As such, the purpose of this study is to quantify availability of AEDs in Nebraska high schools prior to any mandate, advocacy, or requirement. The primary aim was to describe differences in AED accessibility and training between schools of different enrollment size.
2
Methods
This study received approval from the institutional review board at the University of Nebraska Medical Center College of Medicine. A 16-question survey was distributed to all 309 high schools in the state of Nebraska during July 2022 (Appendix A). All high schools, both public and private, that are affiliated with the Nebraska School Activities Association (NSAA) were included, and the survey was sent to the principal of each school via email using Microsoft Forms. Follow-up emails and phone calls were sent over a two-month period to schools that did not respond to the survey.
The survey questions were developed by the authors of this study with the intention of assessing school preparedness for a sudden cardiac emergency. The survey included questions about AED availability (number, locations, and public accessibility), percentage of staff trained to respond to a cardiac emergency, and past use of an AED on that school’s campus. The survey questions, along with the answer response options, are attached (Appendix A).
School size was categorized by its class designation from the NSAA, which divides schools into classes A–D based on their student enrollment to ensure that schools of similar size can compete with each other in athletic and music activities. Class A included the 31 largest schools in Nebraska. The average student enrollment (grades 9–11) for schools that responded to the survey for each class are as follows: Class A: 1508 students; Class B: 672; Class C: 172; Class D: 57 students.
Chi-square analysis was performed to determine differences in survey response rate, percent of schools with AED public access, percent of schools with an AED available at all events, and percent of schools with over 50 % of their staff trained to use an AED between different class sizes. The number of AEDs was plotted against school enrollment, and linear regression was performed to determine correlation.
3
Results
Survey responses were received from 191 (62 %) of 309 high schools. Class A schools had the highest response rate of 71 %, and Class B schools had the lowest response rate of 57 %. The difference in response rate between schools from different class sizes was not significant ( p = 0.639). Class A schools had an average of 3.24 AEDs present at each school. Class B schools had an average of 3.53 AEDs, Class C schools had an average of 2.48 AEDs, and Class D schools had an average of 1.91 AEDs ( Table 1 ). There was no significant difference in the number of AEDs between private schools (34 private schools had an average of 2.08 AEDs) and public schools (157 public schools had an average of 2.37 AEDs) ( p = 0.108). The average number of AEDs reported here is a slight under-estimate, as schools that responded to the survey as having “5 or more AEDs”, of which there were 12 (out of 191 respondents), were credited with having 5 AEDs for the sake of determining these averages.
| High school class | Average enrollment grades 9–11 | Number of schools that survey was distributed to | Number of schools that responded to survey | Response rate | Average number of AEDs per school |
|---|---|---|---|---|---|
| Class A | 1508 | 31 | 22 | 71 % | 3.24 |
| Class B | 672 | 28 | 16 | 57 % | 3.53 |
| Class C | 172 | 75 | 44 | 59 % | 2.48 |
| Class D | 57 | 175 | 109 | 62 % | 1.91 |
| Total | 284 | 309 | 191 | 62 % | 2.33 |
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