6775
Abs ac . – OBJECTIVE: This longi udinal de-
sc ip i e s udy aimed o e alua e cogni i e skills
acquisi ion in basic Ca diopulmona y Resusci-
a ion (bCPR) among a g oup o Yea 5 and Yea
6 p ima y school pupils. The s udy made use o
online ools due o he impossibili y o con en-
ional me hods du ing he COVID-19 lockdown.
MATERIALS AND METHODS: Pupils ecei ed
o mal aining in bCPR. T aining was impa -
ed uni o mly by a eache a he school (quali-
ied in Basic Li e Suppo -BLS- and Ad anced
Li e Suppo -ALS- aining by he CPR Na ion-
al Plan). The skills acqui ed ( hose p oposed
as essen ial o bCPR aining by he Eu opean
Resusci a ion Council) we e e alua ed i een
weeks la e . Skills acquisi ion was e alua ed
by means o an online ques ionnai e de eloped
speci ically o he s udy.
RESULTS : In all he cogni i e skills included
in bCPR aining, he acquisi ion le el achie ed
was o e 65%. Acquisi ion o knowledge o he
ana omical a eas a which ca diac massage mus
be applied and he means o eme gency sys ems
ac i a ion was high, while 25.5% o pupils knew
he o de in which maneu e s should be pe -
o med. Pupils’ sel -con idence and sel -pe cep-
ion o hei capaci y o ac when aced wi h a eal
CPR si ua ion inc eased signi ican ly.
CONCLUSIONS: P ima y school pupils
lea ned all he cogni i e skills in ol ed in bCPR,
showing high le els o skills acquisi ion and
posi i e sel -pe cep ion o hei capaci y o ap-
ply hem.
Key Wo ds:
COVID-19, Online ools, T aining, Basic ca diopul-
mona y esusci a ion (bCPR), P ima y school pupils.
In oduc ion
Some 80% o ex a-hospi al ca dio espi a o y
a es s (EHCRA) ha e an e iology de i ing om
shockable hy hms: en icula ib illa ion (VF) and
pulseless en icula achyca dia (PVTC). A hy h-
mias a e ea ed by means o de ib illa ion. Fo each
minu e ha his is delayed, he p obabili y ha i
will be e ec i e dec eases by 10-12%. D . D ink-
e ’s su i al cu e1 desc ibes he educ ion in he
p obabili y o su i al o each 60 seconds ha he
pa ien spends wi hou ecei ing co ec ly applied
assis ance. Al hough i is di icul o es ima e he
incidence and su i al a es a e EHCRA, some
s udies2-4 p opose a pe cen age o a ound 10%. In
ligh o D . D inke ’s su i al cu e2 his low su -
i al a e may be explained by he ac ha on a -
e age eme gency se ices in Spain ake 11 minu es
o each he pa ien . So, ollowing EHCRA, ea ly
ecogni ion o ca diac a es and immedia e ac i-
a ion o eme gency se ices, as well as applying
ches comp essions a once, will double o e en qua-
d uple he chances o su i al5.
70% o EHCRAs occu in he p esence o a
amily membe o o he pe son. Howe e , he
a es o ci izens capable o implemen ing BLS
when aced wi h a CRA a e below 20% in mos
coun ies, al hough in some coun ies hey each
be ween 60 and 80%. This ep esen s an e iden
public heal h p oblem ha can only be sol ed by
in ol ing he gene al public. I is highly likely
ha he i s pe son o in e ene in a case o EH-
Eu opean Re iew o Medical and Pha macological Sciences 2021; 25: 6775-6781
A. CÁRDENAS-CRUZ1, G. GÓMEZ-MORENO2, A. ROMERO-LINARES1,
D.P. CÁRDENAS-CRUZ3, A. PÉREZ-BAILÓN4, F.M. PARRILLA-RUIZ1
1Depa men o Medicine, School o Medicine, Uni e si y o G anada, G anada, Spain
2Depa men o Medically Comp omised Pa ien s in Den is y, School o Den is y, Uni e si y o
G anada, G anada, Spain
3Depa men o Eme gency Medicine, Uni e si y Clinical Hospi al San Cecilio, G anada, Spain
4In ensi e Ca e Uni , San a Ana Hospi al, Mo il, G anada, Spain
Co esponding Au ho : Ge a do Gómez-Mo eno, DDS, Ph.D, MS; e-mail: ggomez@ug .es
Adap ing e alua ion me hod o skills
acquisi ion in basic ca diopulmona y
esusci a ion among yea 5 and yea 6
p ima y school pupils du ing he COVID-19
lockdown: a pilo s udy
A. Cá denas-C uz, G. Gómez-Mo eno, A. Rome o-Lina es, e al.
6776
CRA will no be a heal hca e p o essional. This
highligh s he impo ance o CPR aining o he
gene al public6. The cu en sequence o s eps o
CPR is he BLS algo i hm ecommended by he
Eu opean Resusci a ion Council (ERC) (2015)7.
Impa ing basic CPR skills o he gene al pub-
lic p esen s wo p oblems: i s ly, he di icul y o
emembe ing he skills ha ha e been impa ed,
and secondly, he cos s in ol ed in implemen ing
public aining p og ams. Fo hese easons, e-
cen deba e8 has ocused on he pe o mance and
cos e ec i eness o online lea ning. I would ap-
pea ha blended lea ning, a combina ion o ace-
o- ace lea ning wi h dis ance lea ning, o e s
a ange o ad an ages. The cu en COVID-19
pandemic has made i necessa y o de elop and
implemen blended lea ning – o en as he i s
and only choice. While cogni i e aspec s can
be augh online, ace- o- ace lea ning emains
necessa y o impa ing p ocedu al skills. So,
a ious CPR aining ini ia i es in ol ing blend-
ed lea ning ha e been implemen ed. Howe e ,
olun a y CPR aining o adul s emains in-
su icien o ain he 15-20% o he popula ion
equi ed o imp o e su i al a es ollowing EH-
CRA. In his con ex , he in oduc ion o compul-
so y aining in CPR in p ima y educa ion o e s
a p omising means o achie ing sus ainable im-
p o emen s o he low a es o BLS skills among
he gene al popula ion9.
The In e na ional Liaison Commi ee on Re-
susci a ion (ILCOR) and he Wo ld Fede a ion o
Socie ies o Anes hesiologis s (WFSA) ha e de-
eloped an ini ia i e known as “Kids Sa e Li es.”
This aims o in oduce CPR aining o school-
age child en all o e he wo ld6. The scheme e-
cei ed he backing o he WHO in 2015. I a gues
ha eaching CPR o all school child en will
p oduce a no able imp o emen in CRA su i -
al a es e e ywhe e. School child en ha e a less
inhibi ed app oach o CRA, he mos inhibi ing
ac o in aking p ac ical measu es in eal li e
being he ea o making mis akes. They also e-
spond be e o ins uc ion and a e keen o lea n
how o help o he s. Mo eo e , by s a ing aining
a an ea ly age i is hoped ha child en will no
o ge he skills hey acqui e. I is also likely ha
hey will go on o each CPR o hei amilies, pu-
pils and eache s being impo an mul iplie s, so
ha he p opo ion o skilled indi iduals among
he gene al popula ion should inc ease conside -
ably10-12. Fo his eason, he compulso y aining
o school child en could ha e a majo impac on
imp o ing CRA su i al a es h ough he in e -
en ions o passe s-by, and also, become a suc-
cess ul mean o sp eading CPR skills among he
popula ion a la ge6,11.
The aim o his pilo s udy was o analyze he
le els o cogni i e skills acquisi ion in basic Ca -
diopulmona y Resusci a ion (bCPR) in a g oup o
Yea 5 and Yea 6 P ima y School pupils using an
online ool, as i was impossible o employ con en-
ional me hods due o he COVID-19 lockdown.
Ma e ials and Me hods
S udy Design
This longi udinal desc ip i e s udy wi h ol-
low-up was app o ed by he Uni e si y o G ana-
da E hics Commi ee (Reg. Nº 1362/CEIH/2020).
The s udy popula ion comp ised 157 pupils a -
ending “La Inmaculada” He manos Ma is as
P ima y School (G anada, Spain), all in yea 5 o
yea 6 and aged 10-12 yea s (Thi d Cycle o Com-
pulso y P ima y Educa ion).
T aining P ocess Cha ac e is ics
Fi s ly, o mal aining in basic Ca diopulmona y
Resusci a ion was p o ided. Subsequen ly, he cog-
ni i e skills acqui ed by he pupils we e e alua ed.
T aining was impa ed uni o mly by a eache a
he school (quali ied BLS and ALS ins uc o by he
CPR Na ional Plan). Be o e pupil aining began,
wo one-day wo kshops we e held o impa (and
ce i y) bCPR skills o a o al o 50 p ima y school
s a 12. Fo he school pupils aking pa in he s udy,
wo aining sessions we e designed based on he
in e na ional ecommenda ions o he ERC1. As his
was a la ge-scale aining scheme, a conside able
quan i y o aining equipmen was needed, in his
case, he Resusci Anne Simula o ma ke ed by Lae -
dal® (S a ange , No way). The eaching impa ed is
he same as o adul s al hough he ocabula y used
mus be adap ed o make i easily unde s ood by a
younge age g oup. All aining was gi en as pa o
he school ime able.
E alua ion P ocess Cha ac e is ics
Skills acquisi ion was e alua ed 15 weeks a -
e he aining phase. The e alua ion me hod (as
in all medical disciplines) had o be adap ed in
esponse o he s a e o ala m and lockdown de-
cla ed by he Spanish go e nmen in esponse o
he COVID-19 pandemic13. This mean de elop-
ing a speci ic online ques ionnai e – he subjec
o he p esen s udy – designed o mee hese
ci cums ances. The pa ame e s e alua ed we e
COVID-19 and basic ca diopulmona y esusci a ion among p ima y school pupils
6777
hose es ablished by he Eu opean Resusci a ion
Council (ERC) as essen ial o bCPR aining (Ta-
ble I). Due o he lockdown, he pa ame e s we e
e alua ed ia an IT pla o m in he o m o an on-
line ques ionnai e. The online ques ionnai e was
p oduced using he online ool Mic oso Fo ms®
(Redmond, WA, USA) and was deli e ed o he
pupils ia he pla o m Mic oso Teams® (Red-
mond, WA, USA) oge he wi h a ask belonging
o he Physical Educa ion syllabus. The pa ici-
pan s we e asked o comple e he ques ionnai e
simul aneously wi hin a se ime able o a oid
any consul a ion be ween he child en.
Resul s
When he e alua ion esul s ha e been collec -
ed, hey unde wen quan i a i e s a is ical analy-
sis. Rega ding cogni i e bCPR skills, hese we e
assessed as 12 dicho omous a iables (Yes/No
answe s). Fo all he cogni i e skills ha make up
bCPR ( a iables 2-12) 60% o he pupils espond-
ed posi i ely (Table II). O he skills ha ob ained
mo e han 60% posi i e answe s, all excep one
( a iable 4) ob ained o e 70%. I should be no -
ed ha he e alua ion unde COVID-19 lockdown
was pe o med 15 weeks a e he aining ses-
sions. Analysis o he 12 a iables showed ha
he skills ha we e acqui ed mos e ec i ely
we e: 1) knowledge o he ana omical spo whe e
con inuous ca diac massage should be applied; 2)
knowledge o he eme gency elephone numbe
o call and how o make he call; 3) knowledge
o how long o con inue CPR. The child en’s
sel -pe cep ion o he skills lea n and hei ca-
paci y o apply hem is shown in Table III.
Discussion
T adi ionally, skills aining and he e alua ion
o i s e icacy ha e been based on ace- o- ace
class oom ac i i y14. The s a e o ala m and lock-
Table I. Real ime PCR p ime s.
Quali a i e a iables
1. Sex
Quan i a i e a iables
2. Age
3. Days o aining comple ed
E alua ion o bCPR cogni i e skills
Quali a i e a iables (Dicho omous ques ions: Yes/No)
1. Does he/she know he o de in which bCPR p ocedu es a e ca ied ou ?
2. Does he/she know how o in e p e he shou ing and shaking echnique o check o un esponsi eness?
3. Does he/she know which i al sign ( espi a ion) o check o de ec ca diopulmona y a es ?
4. Does he/she know he echnique o de ec ing ca diopulmona y a es ? (Head- il -chin-li /look, lis en, eel)
5. Does he/she wha elephone numbe o call o ac i a e eme gency se ices and how o make he call?
6. Does he/she unde s and he impo ance o con inuous co ec ly applied ca diac massage?
7. Does he/she know whe e on he ana omy o apply con inuous co ec ly-applied ca diac massage?
8. Does he/she know how o gi e ches comp essions co ec ly?
9. Does he/she know how o gi e mou h- o-mou h esusci a ion and he o de in which he maneu e s a e ca ied ou ?
10. Does he/she know how many comp essions make up each cycle?
11. Does he/she know how many insu la ions make up each cycle?
12. Does he/she know how long o con inue CPR o ?
E alua ion o sel -pe cep ions o lea ning ecei ed and abili y o ac
Quali a i e a iables (O dinal ques ions: Incapable/Low capabili y/Able/Ve y able)
1. Sel -pe cep ion o abili y o ac in a eal CPA si ua ion be o e ecei ing aining.
2. Sel -pe cep ion o abili y o ac in a eal CPA si ua ion a e ecei ing aining.
Quali a i e a iables (O dinal ques ions: Incapable/Low capabili y/Able/Ve y able)
3. Di icul y expe ienced in bCPR aining
Quali a i e a iables (Dicho omous ques ions: Yes/No)
4. Belie in abili y o each an adul how o ca y ou he p incipal maneu e s in ol ed in bCPR.
Quan i a i e a iables
5. Sel -assessmen (0-10) o knowledge and unde s anding o bCPR
A. Cá denas-C uz, G. Gómez-Mo eno, A. Rome o-Lina es, e al.
6778
Table II. Compa ison o a iables analyzed.
Va iable e alua ed Yes (%) No (%)
1. Does he/she know he o de in which bCPR p ocedu es a e ca ied ou ? 25.5 74.5
2. Does he/she know how o in e p e he shou ing and shaking echnique o check 74.5 25.5
o un esponsi eness?
3. Does he/she know which i al sign ( espi a ion) o check o de ec ca diopulmona y a es ? 84.9 15.1
4. Does he/she know he echnique o de ec ing ca diopulmona y a es ? 66 34
(Head- il -chin-li /look, lis en, eel)
5. Does he/she wha elephone numbe o call o ac i a e eme gency se ices and 96.2 3.8
how o make he call?
6. Does he/she unde s and he impo ance o con inuous co ec ly applied ca diac massage? 80.2 19.8
7. Does he/she know whe e on he ana omy o apply con inuous co ec ly-applied 98.1 1.9
ca diac massage?
8. Does he/she know how o gi e ches comp essions co ec ly? 84 16
9. Does he/she know how o gi e mou h- o-mou h esusci a ion and he o de in which 71.7 28.3
he maneu e s a e ca ied ou ?
10. Does he/she know how many comp essions make up each cycle? 79.2 20.8
11. Does he/she know how many insu la ions make up each cycle? 75.5 24.5
12. Does he/she know how long o con inue CPR o ? 86.8 13.2
Table III. Main esul s ob ained in he s udy.
COVID-19 and basic ca diopulmona y esusci a ion among p ima y school pupils
6779
down decla ed by he Spanish go e nmen in e-
sponse o he COVID-19 pandemic suddenly pu
an end o class oom lea ning a all educa ional
le els. This obliged educa o s o seek al e na i e
means o eaching based on IT pla o ms and
online aining and e alua ion. In his s udy, he
aining p og am had al eady been p o ided in
ace- o- ace classes du ing he mon hs jus be o e
he pandemic a i ed in Spain. Bu he e alua-
ion phase o he p og am had o be designed and
implemen ed du ing he mon h o Ma ch, since
i was impossible o b ing he schoolchild en o-
ge he a school o assessmen due o he lock-
down and school closu e. Faced wi h his si ua-
ion, i was necessa y o design a ool ha would
p o ide cogni i e skills assessmen o all he pa -
icipan s in bCPR aining.
P ima y school is conside ed a sui able se ing
o ini ia ing bCPR aining o se e al easons:
almos 100% o he popula ion a ends p ima y
school15; young people end o equen he pub-
lic spaces (s ee s, shopping cen e s, pa ks, e c.)
whe e EHCRAs occu ; ha ing ecei ed bCPR
aining, hey can ac as po en ial esusci a o s.
Since 2003-2004, bo h ILCOR and AHA ha e
ecommended he in oduc ion o esusci a ion
aining in p ima y educa ion15. I has been shown
ha child en ac as ‘mul iplie s’ by sha ing hei
newly acqui ed knowledge wi h amily membe s
and o he s9,12,16. The esul s o he p esen s udy
suppo his idea, gi en ha as many as 96.2% o
he pa icipan s s a ed ha hey we e willing and
able o each bCPR o an adul . In his way, he e
is inc easing e idence ha p ima y school pupils
a e an app op ia e and ecep i e g oup o bCPR
aining. Ne e heless, some in es iga ions ha e
shown ha i is only a e he age o 13 yea s (o
50 kg body weigh ) ha an indi idual eaches he
physical condi ions equi ed o apply CPR ech-
niques e ec i ely15. The e is a di ec associa ion
be ween age, weigh , heigh and BMI and he
dep h o ches comp essions applied17,18. In any
case, he age ecommended o aining indi id-
uals in manual CPR skills (ca diac massage and
mou h- o-mou h esusci a ion) emains unclea ,
al hough di e en s udies ha e es ablished an
age ange o 10-13 yea s. The popula ion e al-
ua ed in he p esen s udy ell wi hin his ange.
When e alua ing he ou comes o bCPR aining,
se e al s udies12,19-21 ha e no ound di e ences in
cogni i e skills acquisi ion be ween di e en age
g oups, which makes i clea ha p ima y school
pupils a e able o lea n and e ain bCPR and BLS
skills and knowledge.
The esul s o he p esen wo k concu wi h
indings in he s udies ci ed abo e. Wi hin ou
s udy popula ion, he le el o cogni i e skills ac-
quisi ion was o e 65% 15 weeks a e aining.
Mo eo e , in esponse o he ques ion “How did
you ind CPR aining?” mo e han 60% eplied
ha i was “easy” o “ e y easy,” while only
1.89% classed i as “ e y di icul .” As in o h-
e simila s udies, he ques ionnai e e alua ed
knowledge (cogni i e skills) and psychological
aspec s ela ed o bCPR, bu no echnical pe o -
mance o he maneu e s impa ed. Ne e heless,
he mos impo an aspec o he aining was
no he acquisi ion o high-quali y CPR skills
bu a he o imp o e he pa icipan s’ a i ude
o CPR and o ins ill a sense o i s impo ance;
his is known as “gene a ing a cul u e o ca -
diopulmona y esusci a ion”. The p esen esul s
showed ha wo hou s heo e ical and p ac ical
aining had a posi i e e ec on he pupils’ con i-
dence and sel -pe cep ion o he abili ies hey ac-
qui ed, so ha he numbe o pa icipan s who el
p epa ed o o e assis ance doubled as a esul o
aining ( om 40 o 85%). This e lec s and e-
in o ces he indings o o he s udies ega ding
he impac hese sho aining sessions ha e on
pupils’ con idence in hei own knowledge and
capabili y22,23.
A s udy22 conduc ed a a school in Munich in
2013 showed ha s uden s’ lea ning was e ained
and emained high nine mon hs a e aining al-
hough hei sel -con idence dec eased conside -
ably. In he p esen s udy, e alua ion ook place 15
weeks a e aining, and i would be in e es ing o
ca y ou a second e alua ion a some poin in he
u u e and a emp o es ablish an app op ia e ime
lapse be o e e eshe aining becomes necessa y.
When i comes o impa ing aining o bo h
cogni i e and psychological capaci ies ela ed o
CPR o p ima y school child en, o he ac o s
come in o play, such as psychosocial s eng hs
and obs acles de i ing om hei age. One o
he i ems in he ques ionnai e analyzed he eel-
ings in ol ed in no in e ening in a possible
CRA. Among he mos common esponses was “I
would be a aid o making a mis ake ha makes
he si ua ion wo se”. This is a simila inding o
o he s udies24, which ha e highligh ed his ea
as he mos inhibi ing ac o when he indi idual
is aced wi h a eal CRA si ua ion. O he com-
mon psychosocial ba ie s we e “adul s will no
le me ac because I am a child,” and “I would
be disgus ed o oo shy o gi e mou h- o-mou h
esusci a ion”. The la e o e s an a gumen in
A. Cá denas-C uz, G. Gómez-Mo eno, A. Rome o-Lina es, e al.
6780
a o o child en only gi ing CPR in he o m o
ches comp essions. Bu he s udy popula ion’s
young age had e y posi i e aspec s. Thei in e -
es , keenness, and ecep i eness o new knowl-
edge was ou s anding. Mo eo e , p ima y school
child en a e much less in luenced by social p es-
su es and less anxious abou pa icipa ing in CPR
han a la e s ages o educa ion25.
One o he mos common ques ions aised by
he child en when hey inished aining con-
ce ned he use o an ex e nal au oma ic de ib illa-
o (EAD). Many coun ies do no allow EAD use
by mino s al hough i has been shown ha wi h
a li le aining, a child as young as six yea s can
use an EAD sa ely24. I could be bene icial o in-
clude EAD aining, p o iding his complies wi h
he legisla ion in o ce locally.
Analysis o he p esen esul s, oge he wi h
p e iously published scien i ic li e a u e18,20,23
con i m he need o es ablish a o mal and s an-
da dized eaching me hod wi hin p ima y educa-
ion (yea s 5 and 6), inco po a ing CPR aining
in o he syllabus26,27. Fu he esea ch is needed
o es ablish he co ec me hods and o analyze
e en ion o he skills acqui ed. P ocedu al skills
aining and aining in posi i e a i udes owa ds
CPR may be addi ional op ions, accompanied by
assessmen o hei e icacy in p ac ice.
Conclusions
P ima y school pupils in yea s 5 and 6 we e
able o lea n all he cogni i e skills included in
bCPR uni o mly. A e aining, hey showed a
high le el o skills acquisi ion and good sel -pe -
cep ion o hei abili y o ac in a CPA si ua ion.
The e alua ion o skills acquisi ion was ca ied
ou hanks o he de elopmen o an online ool
de eloped specially o his s udy.
Con lic o In e es
The Au ho s decla e ha hey ha e no con lic o in e es s.
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