Impact of intensive basic life support training as part of cardiac rehabilitation program: Targeting family versus non-family bystanders

Cardiac arrest is the most common cause of death and can result in severe neurological disability in survivors. The extent of hypoxic-ischemic brain injury is determined by the duration of circulatory arrest. The estimated annual incidence out-of-hospital cardiac arrest (OHCA) is 275,000 in Europe ¹ and 350,000 in the United States. ² Prompt recognition of OHCA and bystander intervention may significantly increase survival rates. In such an emergency, it is critical that bystanders call for emergency services and initiate cardiopulmonary resuscitation (CPR) within the first few minutes following cardiac arrest. Subsequently, the American Heart Association detailed a “chain of survival,” which emphasized four priorities: (1) early access to help, (2) early basic life support (BLS), (3) early defibrillation, and (4) early advanced life support. Successful performance of these guidelines significantly improves the prognosis for victims of OHCA. ³

Cardiovascular disease is the most common cause of OHCA. Exercise-based cardiac rehabilitation is important for the secondary prevention of cardiovascular disease. In addition, cardiac rehabilitation provides health education and CPR training. The majority of bystanders in proximity to OHCA victims are immediate family members, as 70% of OHCA events occur at home. ⁴ However, most people have poor BLS skills. It follows that teaching family members of patients with cardiovascular disease BLS skills may effectively reduce the mortality rate of OHCA.

In a previous study González-Salvado et al. observed the efficacy of combining an initial BLS training (G-Stan) with hands-on rolling refreshers (G-CPR) in their cardiac rehabilitation program. The study revealed that integrating G-CPR in the cardiac rehabilitation training program improved participants’ retention of knowledge and skills in BLS compared with G-Stan. Furthermore, this program improved self-confidence with respect to BLS initiation. ⁵ Based on these findings, González-Salvado et al. ⁶ conducted a subsequent study that aimed to measure confidence levels and skills six months following intensive BLS training, which consisted of two months’ training with refreshers. Their participants included those with relatives suffering from acute coronary syndrome and/or following revascularization. This most recent study provided intriguing evidence that participants from G-CPR programs displayed markedly higher skill and confidence levels to effectively implement BLS six months after initial training.

While most bystanders of patients who suffer OHCA are family, 21% of bystanders have no relationship to the patient. ⁷ Remarkably, non-relative bystanders were more likely to deliver high quality BLS than family, likely due to fewer psychological barriers. ⁸ An interesting follow-up study might compare performance of BLS in non-family bystanders who receive G-CPR with those guided through BLS by a 911 dispatcher.

In this study, the duration of training was quite time consuming at two months. The 16% participant attrition rate may be largely due to length of training. In addition, extensive training can be costly, the average cost for a BLS course lasting one half-day being US$60 to US$80. Ideally, BLS training would be conservative in terms of cost and training time. One potential solution is to teach simplified BLS skills to school-aged children with annual refreshers throughout their time in the educational system.^9,10 For adults, perhaps an up-to-date BLS certification should be mandatory for renewal of a driver’s license. Regardless, refresher courses should be hands on, community based, available online and easily accessible.

Overall, González-Salvado et al. found excellent results from intensive BLS training with two months of refreshers. Given the significant morbidity and mortality associated with OHCA, public BLS training with regular refreshers should be a priority for our society today. Potential solutions include teaching BLS to school-aged children with annual refreshers and requiring an up-to-date BLS certificate for renewal of a driver’s license.