Sudden cardiac arrest accounts for 15–20% of all deaths worldwide. Reference Srinivasan and Schilling1 Several studies have demonstrated that prompt recognition of a cardiac arrest, early cardiopulmonary resuscitation, and defibrillation confers substantial survival benefit for out-of-hospital sudden cardiac arrest. Indeed, a 41–74% benefit has been reported when cardiopulmonary resuscitation training is administered within 3–5 min of collapse. Reference Drezner, Rao, Heistand, Bloomingdale and Harmon2–Reference Swor, Grace, Mcgovern, Weiner and Walton7 A 7–10% decline in survival for every minute that defibrillation is delayed has prompted several health organisations to encourage the installation of automated external defibrillators in major public areas. 8–Reference Larsen, Eisenberg, Cummins and Hallstrom10 Most sporting organisations also mandate automated external defibrillators in sporting arenas. Reference Borjesson, Serratosa and Carre11,Reference Malhotra, Dhutia and Gati12
The sudden death of a young individual is a devastating tragedy for family and friends, stirring deep emotions and raises concerns about the vulnerability of other children and adolescents in society. Sudden cardiac death is a rare phenomenon, with 8–12 young healthy individuals passing away every week in the United Kingdom. Reference Papadakis, Sharma, Cox, Sheppard, Panoulas and Behr13 Retrospective registries that record sudden cardiac death in young athletes and non-athletes estimate an incidence rate ranging between 0.1 and 6.8 deaths per 100,000 young individuals. Reference Drezner, Rao, Heistand, Bloomingdale and Harmon2,Reference Papadakis, Sharma, Cox, Sheppard, Panoulas and Behr13–Reference Malhotra, Dhutia and Finocchiaro18 This is probably an underestimate as no mandatory reporting systems currently exist. The prevalence is regrettably hard to establish due to heterogeneity in study methodology and populations studied.
The effectiveness of early cardiopulmonary resuscitation training and defibrillation has also been demonstrated in young individuals. Several cases of successful resuscitation of students during athletic events and functions held at high schools and colleges have now been reported. Reference Drezner, Rogers, Zimmer and Sennett3,Reference Drezner, Toresdahl, Rao, Huszti and Harmon19–Reference Coris, Miller and Sahebzamani21 Politicians and school administrators are increasingly recognising that this is an important public health concern. The availability of automated external defibrillators in schools is now on the rise in many countries including locally in Malta. Several countries have also created a legal framework to facilitate this process. Automated external defibrillators in most schools are now obligatory in one-third of United States of America states since February 2016. Reference Sherrid, Aagaard and Serrato22 They are endorsed by the Department of Education in the United Kingdom. 23 However, implementation is nation dependent. Most secondary schools in London do not have an automated external defibrillator readily available, Reference Salciccioli, Marshall and Sykes24 whilst an Italian bill outlining the obligatory installation of automated external defibrillators in schools has been approved in 2021. Reference Scapigliati, Semeraro and di Marco25 To date, the Ministry of Education in Malta has not yet endorsed nor provided any relevant recommendations to schools. There is also no legal framework to support the installation of automated external defibrillators in public places, hence this study.
All adolescents attending Year 5 secondary school classes in Malta (mean age 15 years) were invited to undergo cardiac screening that included a physician-led assessment together with ECG acquisition in schools. This BEAT-IT programme was a first of its kind, effectively screening 0.6% of the entire Maltese population. Nine (0.3%) students were given a diagnosis linked to sudden cardiac death, and another 27 (1.0%) are under surveillance because of symptoms and/or a pre-clinical pathological ECG findings. Reference Abela, Xuereb and Camilleri26 These outcomes led to a local awareness campaign regarding cardiac arrest prevention and heart disease in young individuals. Early defibrillation and the chain of survival are heavily dependent on automated external defibrillator availability and good cardiopulmonary resuscitation training. Device location and the number of automated external defibrillators installed in schools are key players in this process. Cardiopulmonary resuscitation (CPR) training and recertification are also vital. The main objectives of this study were to evaluate these factors, primarily a) assessing CPR competence and certification amongst school staff, together with b) automated external defibrillator availability in all secondary schools in Malta and Gozo.
Methodology
A cross-sectional study among secondary schools in Malta and Gozo was conducted between March and November 2020. A quantitative written survey was distributed electronically to all heads of schools or school nurses (where available). This consisted of 16 questions, comprised of three main sections a) school details, b) automated external defibrillators availability, and c) basic life support competence amongst staff. Geographic districts were applied as defined by the Malta National Statistics Office. 27 Data were recorded as categorical variables or as a Likert scale (where relevant).
Ethical Approval
This study conforms to the principles stated in the Declaration of Helsinki and was approved by the University of Malta Research Ethics Committee (UREC updated approval 34/2017). Approval was also obtained from the Ministry of Education.
Statistical analysis
Computations were performed using SPSS V.23 (IBM, Armonk, New York, United States of America). Categorical variables were presented as frequencies and percentages. Chi-squared test was used to compare groups. A p value of < 0.05 was considered statistically significant.
Results
Forty out of 54 schools (74.1%) completed the questionnaire. Most schools catered for mixed genders (57.5%). The majority were in the Northern Harbour district (37.5%). Two schools (5.0%) had a documented sudden cardiac arrest in one of their pupils in the past 10 years, one on school premises. The majority (n = 35, 87.5%) agreed that sudden cardiac arrest prevention is an important health concern (Table 1). Almost all schools favoured a systematic cardiac screening programme in schools (undecided n = 1, 2.6%; agree n = 9, 23.7%; strongly agree, n = 28, 73.7%).
Table 1. Introductory questions
The next section of the questionnaire addressed automated external defibrillator availability (Table 2). The majority have heard of an automated external defibrillator and its function (n = 39, 97.5%). Most schools are equipped with an automated external defibrillator (n = 37, 92.5%). Only one automated external defibrillator on site is typically present (n = 27, 75.0%). Most schools reported that their automated external defibrillator/s were in an easily accessible area (n = 35, 97.2%), defined in this study as “an area of no further than a 2-minute brisk walk from places in which they were likely to be used.” Despite this, almost half of the schools did not have a risk assessment prior to automated external defibrillator installation (n = 17, 47.2%). This consequently led to automated external defibrillators not being available on every floor in most (n = 37, 97.2%) and not being close to a sporting facility in almost one-third (n = 11, 30.6%).
Table 2. Automated external defibrillators in secondary schools
History of sudden cardiac arrest in a school pupil did not have any influence on the availability of automated external defibrillator (p = 0.860) or proximity to a sporting facility (p = 0.722). History of sudden cardiac arrest at school did not positively influence the number of installed automated external defibrillators (≤1 versus ≥ 2 automated external defibrillator, p = 0.413), but there seemed to be a direct relationship between history of sudden cardiac arrest at schools and automated external defibrillator availability on every floor (p = 0.056). More automated external defibrillators on school grounds did not influence the likelihood of device installation close to a sporting facility (p = 0.432). This was also independent of pupil gender (p = 0.691) and school location (p = 0.222).
Most schools do not organise regular cardiopulmonary resuscitation training courses (n = 21, 58.3%) (Table 3). The majority have staff certified in life support (n = 35, 89.7%). A quarter of schools report more than five certified staff members (n = 8, 23.5%), and the majority have undergone recertification (n = 28, 82.4%). The number of automated external defibrillators on site did not increase the likelihood of having cardiopulmonary resuscitation training courses organised at school (p = 0.607). Additionally, there was no association between the number of certified staff members and the number of installed automated external defibrillators (p = 0.806).
Table 3. Cardiopulmonary resuscitation competence and certification
Discussion
The prevalence of sudden cardiac death in children and adolescents at schools is low, Reference Hwang, Do and Lee28 yet 5% of schools actually had a sudden cardiac arrest recorded. Up to 79% of cases are witnessed, Reference Drezner, Rao, Heistand, Bloomingdale and Harmon2 77% receive bystander cardiopulmonary resuscitation training. Reference Swor, Grace, Mcgovern, Weiner and Walton7 The survival rate is far better when defibrillators are readily available in public places. Reference Baekgaard, Viereck, Møller, Ersbøll, Lippert and Folke4,Reference Drezner, Toresdahl, Rao, Huszti and Harmon19 Numerous international bodies are not in favour of automated external defibrillator installation in public areas. 8,23,29 The hospital survival rate after sudden cardiac arrest in schools equipped with an automated external defibrillator is 70% when compared to 8% in the overall population of school age children. Reference Drezner, Toresdahl, Rao, Huszti and Harmon19,Reference Sherrid, Aagaard and Serrato22 Shockable rhythms are often present at presentation, an important factor in determining outcome. Reference Drezner, Rogers, Zimmer and Sennett3 Most schools in this cohort acknowledge that sudden cardiac arrest prevention is an important health topic (92.5%). The majority (92.5%) have at least one automated external defibrillator installed on school premises, substantially better than the results reported in a study carried out across schools in London (28.0%). Reference Salciccioli, Marshall and Sykes24
Location and availability of installed automated external defibrillators are also important factors. Sports facilities and play areas are known high-risk areas for sudden cardiac arrest in young individuals. Reference Hwang, Do and Lee28,Reference Marijon, Tafflet and Celermajer30,Reference Becker, Eisenberg, Fahrenbruch and Cobb31 Despite 52.5% of schools in this study claiming a risk assessment was conducted prior to automated external defibrillator installation, most schools do not have an automated external defibrillator on every floor (97.2%). A significant proportion (30.6%) do not have automated external defibrillators installed close to sporting facilities. This is a major public health concern as this may substantially prolong time to defibrillation. Most have at least one staff member certified in life support (89.7%), yet schools do not often organise life support courses (58.3%). This highlights that some staff members have taken this on themselves, rather than relying on the institution to support such initiatives. Basic life support training programmes for students are unfortunately not part of the education curriculum locally, a service which is often included in curricula internationally. Reference Salciccioli, Marshall and Sykes24,Reference Süss-havemann, Kosan and Seibold32
Limitations
The study was a cross-sectional study. Data were unfortunately only collected from heads of schools or school nurses, heavily relying on a single individual for a school assessment. The availability and number of installed automated external defibrillators are typically dependent on the number of pupils. This was not addressed in the questionnaire so as not to risk jeopardising confidentiality.
Conclusion
Schools do not only offer education to students. Students also gather for social and sporting events. Sport complexes are often used by sporting clubs or communities for various athletic activities. The vast number of individuals making use of these facilities certainly increases the likelihood of a sudden cardiac death, which is why automated external defibrillator availability and individuals competent in life support is of paramount importance. This study highlights that despite our best efforts, several key factors in Maltese schools still need to be addressed in order to improve the chain of survival.
A multifaceted approach to address cardiac arrest prevention in public communities is required. Defibrillator availability is only the tip of the iceberg. Stigma and perception in society are key factors in this important health topic. Educating the young community should be at the forefront of any national cardiac arrest prevention strategy. Teaching basic life support to the young community is a must. Robust legislation would strongly pave the way towards policy implementation, as in the newly approved Italian law. Reference Scapigliati, Semeraro and di Marco25 The SportAct framework should also be extensively revised, including sections on the well-being of the athlete and cardiac arrest prevention. 33 The outcomes of this study are the first to objectively assess the current pitfalls in cardiac arrest management in schools.
Acknowledgements
All authors would like to thank all school administrators and school nurses for completing the study questionnaires.
Author contribution
MA was responsible for conceptualisation, methodology, formal analysis, investigation, writing original draft, and visualisation. VG was responsible for conceptualisation, reviewing, and editing. MAS was responsible for visualisation, reviewing and editing, supervision, and project administration.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of interest
None.
