Response to Cardiac Arrest; The Emergency Response Plan for Schools

Published online before print January 5, 2004, doi:10.1161/01.CIR.0000109486.45545.AD
(Circulation. 2004;109:278-291.)
© 2004 American Heart Association, Inc.

AHA Scientific Statement
Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies
The Medical Emergency Response Plan for Schools: A Statement for Healthcare Providers,
Policymakers, School Administrators, and Community Leaders*
, Writing GroupMary Fran Hazinski, RN, MSN; David Markenson, MD, EMT-P; Steven Neish, MD; Mike
Gerardi, MD; Janis Hootman, RN, PhD; Graham Nichol, MD, MPH; Howard Taras, MD; Robert Hickey, MD;
Robert O’Connor, MD; Jerry Potts, PhD; Elise van der Jagt, MD, PhD; Stuart Berger, MD; Steve
Schexnayder, MD; Arthur Garson, Jr, MD, MPH; Alidene Doherty, RN; Suzanne Smith

Key Words: AHA Scientific Statements • heart arrest • pediatrics • resuscitation • defibrillation

   Introduction

This document introduces a public health initiative, the Medical Emergency Response Plan for Schools.
This initiative will help schools prepare to respond to life-threatening medical emergencies in the first
minutes before the arrival of emergency medical services (EMS) personnel.
This statement is for healthcare providers, policymakers, school personnel, and community leaders. It
summarizes essential information about life-threatening emergencies, including details about sudden
cardiac arrest (SCA). This statement describes the components of an emergency response plan, the
training of school personnel and students to respond to a life-threatening emergency, and the equipment
required for this emergency response. Detailed information about SCA and cardiopulmonary resuscitation
(CPR) and automated external defibrillator (AED) programs is provided to assist schools in prioritizing and
preparing for emergencies to maximize the number of lives saved.
Life-threatening emergencies can happen in any school at any time. These emergencies can be the result
of preexisting health problems, violence, unintentional injuries, natural disasters, and toxins. In recent
years, stories in the lay press have documented tragic premature deaths in schools from SCA, blunt
trauma to the chest, firearm injuries, asthma, head injuries, drug overdose, allergic reactions, and
heatstroke. School leaders should establish an emergency response plan to deal with life-threatening
medical emergencies in addition to the emergency plan for tornados or fires.
This statement has been endorsed by the following organizations: American Heart Association (AHA)
Emergency Cardiovascular Care Committee, American Academy of Pediatrics, American College of
Emergency Physicians, American National Red Cross, National Association of School Nurses, National
Association of State EMS Directors, National Association of EMS Physicians, National Association of
Emergency Medical Technicians, and the Program for School Preparedness and Planning, National
Center for Disaster Preparedness, Columbia University Mailman School of Public Health. This statement
was also reviewed by the Centers for Disease Control Division of School and Adolescent Health.
This statement includes all of the recommendations made in the 2001 Guidelines for Emergency Medical
Care in School published by the American Academy of Pediatrics.1 It is consistent with the position of the
AHA statement on use of AEDs in children,2 the National Association of School Nurses’ statement on the
use of AEDs in schools,3 the statement from the National Association of EMS Physicians about the use of
AEDs in children,4 the emergency planning in athletics statement of the National Athletic Trainers’
Association,5 and the American Lung Association Asthma Alert for Teachers.6

   Background

Magnitude of the Problem
School nurses, athletic trainers, and teachers are often required to provide emergency care during the
school day and for extracurricular activities, including sports. In a survey of elementary and high school
teachers in the Midwest, 18% of all teachers surveyed indicated that they personally provided some
aspect of emergency care to more than 20 students each academic year, and 17% indicated that they
had responded to =" src="/math/ge.gif" border=01 life-threatening student emergency during their
teaching career.7 A survey of school nurses in New Mexico documented that each year, 67% of schools
activated the EMS system for a student and 37% of the schools activated the EMS system for an adult.8
Unfortunately, data on the type and severity of emergency calls from schools to EMS systems are limited.
A review of the medical literature yielded no published reports of the national frequency and causes of life-
threatening medical emergencies in schools. Information in the present statement was gathered from the
medical literature, regional and statewide surveys, and registries of isolated problems.
School medical emergencies can involve students or adults. All schools have adult faculty and staff, and
most schools host large numbers of adults during extracurricular activities (eg, sports events, drama
productions, community meetings). As noted above, each year, more than one third of schools may have
an emergency that involves an adult and requires activation of the EMS system.8 The data on adult life-
threatening medical emergencies in schools were derived from the most frequent causes of death in
adults reported by the National Center for Health Statistics9 and the most common causes of work-related
fatalities.10,11R11-141303

   Life-Threatening Emergencies in Children and Adolescents

Noncardiac Causes of Emergencies
In children and young adults, injuries cause more childhood deaths than all other diseases combined.9
Unless an injury involves commotio cordis (a sudden blow to the chest), injury deaths typically are
associated with difficulty breathing or development of shock (low blood pressure) due to blood loss. In
such cases, the heart often slows and then stops so that the cardiac arrest is a secondary (rather than a
primary or sudden) event.12 Victims of injuries require early activation of EMS, support of breathing, and
control of hemorrhage and are unlikely to need treatment with a defibrillator.
The AHA modified the Adult Chain of Survival to emphasize the prevention of injuries and other causes of
death and the need for immediate bystander CPR for children.12 The links in the AHA Infant and Child
Chain of Survival are as follows:
1. Prevention of injury and other causes of cardiac arrest
2. Early CPR
3. Early activation of the EMS system
4. Early advanced care
The Intermountain Injury Control Research Center at the University of Utah compared statewide reasons
for EMS dispatch for children 5 to 18 years of age at schools with reasons for EMS dispatch for children at
nonschool locations during a 3-year period (see Table 1).13 Injuries accounted for a greater proportion of
school-based EMS calls than other EMS calls for children; most school injuries occurred during sports
activities, and 11 resulted in permanent paralysis.13

Because injuries are the most common life-threatening emergencies encountered in children and
adolescents in or out of schools, teachers, school nurses and physicians, and athletic trainers should
know the general principles of first aid (eg, how to ensure scene safety and assess responsiveness, how
to use personal protective equipment when in contact with blood or other body fluids, when and how to
phone the EMS system, and when it is acceptable to move a victim). In addition, first aid rescuers must be
able to control bleeding, recognize and treat shock, immobilize the spine, warm hypothermia victims, cool
heatstroke victims, detect and treat hypoglycemia, support the airway, and provide CPR and use an AED
when needed. These skills are taught in 1-day first aid courses that teach first aid, CPR, and AED use.

SCA in Children and Adolescents
SCA is the sudden cessation of cardiac activity so that the victim becomes unresponsive, with no normal
breathing and no signs of circulation. Unless the victim receives immediate CPR and other treatment to
restore normal cardiac activity, he or she will die. Although the precise incidence of SCA in children is
unknown, it is not a leading cause of death in children and young adults.
Response to SCA is a major focus of this statement. Although SCA is relatively uncommon in children and
young adults, victims are more likely to survive SCA than prehospital traumatic cardiac arrest if they
receive prompt support and treatment.
When SCA does occur in children and young adults, it may be precipitated by ventricular fibrillation (VF)
or rapid ventricular tachycardia (pulseless VT). These abnormal heart rhythms in children are typically
caused by inherited or congenital cardiac conditions or by acute medical problems that cause
inflammation of the heart. Examples of conditions that may be familiar to school nurses, physicians, and
parents include long-QT syndrome, hypertrophic cardiomyopathy, abnormal development of the coronary
arteries, aortic dissection, myocarditis, and congenital aortic stenosis.19 Many of these conditions will not
be detected during routine screening for school physicals or sports activities,20,21R21-141303 so SCA
may be the first sign of these problems. Vigorous exercise appears to act as a trigger for lethal
arrhythmias.21
SCA may also result from commotio cordis, a blow to the chest that causes VT or VF. Each year 5 to 10
cases of commotio cordis are reported nationwide for victims of all ages.21–23R22-141303R23-141303
A statewide survey of SCA in athletes in Minnesota conducted by Maron et al24,25R25-141303 was the
basis for estimating the risk of SCA in high school athletes, which is thought to be 0.5 to 1.0 per 100 000
high school athletes (or 1 per 200 000 to 1 per 100 000) per year.21,25R25-141303 This risk is 1/100 to
1/200 of the risk reported in the adult population 35 years of age and older.26 In 1999, an estimated 5
000 000 athletes competed in varsity athletics in 34 486 public and private high schools throughout the
United States. Extrapolation from the Maron Minnesota data predicted 25 to 50 episodes of SCA
nationwide among all high school athletes per year.
The National Center for Catastrophic Sports Injury Research (NCCSIR) tracks voluntary reports of serious
injuries and deaths that occur during training or competition in male and female high school and college
sports.27 The NCCSIR reports deaths attributable to an injury (direct injury death) and those not
attributable to an injury (indirect nontraumatic death). In 2000, the NCCSIR reported 15 deaths of high
school athletes nationwide: Twelve deaths were caused by SCA (indirect nontraumatic death), 2 deaths
resulted from direct injury with commotio cordis (blow to the chest), and 1 death resulted from a brain
injury.28 The 14 reported cardiac deaths among 5 000 000 high school athletes are lower than the 25 to
50 fatalities predicted by the Maron Minnesota data and yield an incidence of 0.28 cardiac deaths per 100
000 high school athletes, or 1 death per 357 000 high school athletes.
Over a 10-year period from July 1983 to June 1993, the NCCSIR reported 126 nontraumatic sports deaths
in high school athletes and 34 deaths in college athletes, or an average of 16 reported deaths per year
nationwide.29 Most of these deaths were caused by cardiovascular conditions, especially hypertrophic
cardiomyopathy and congenital anomalous coronary arteries. Estimated death rates in male athletes were
5-fold higher than those in female athletes (0.747 versus 0.133 per 100 000 athletes per year; P<0.0001)
and 2-fold higher in male college athletes than in male high school athletes (1.45 versus 0.66 per 100 000
athletes per year; P<0.0001).29
The NCCSIR database includes only voluntary reports of deaths or injuries at athletic activities sanctioned
and sponsored by high schools and colleges. It does not include deaths or injuries that occur during
routine class hours, physical education classes, or pickup sporting activities. Despite these limitations, the
NCCSIR represents the best ongoing source of data on high school athletic injuries and death.
There is little information about SCA among high school students who do not compete in athletics or about
SCA among elementary school students. Although SCA has been reported in nonathletic adolescents
during sedentary activities, the risk of SCA appears to be lower in high school students who do not play
competitive sports than in athletes.21,24,30R24-141303R30-141303 When the limited data from EMS
systems are examined,31 the risk of SCA in elementary school–age children appears to be much lower
than that reported in high school–age students who are not athletes and substantially lower than that
reported in high school athletes.
Because the Maron and NCCSIR registries provide the most concrete data available, the risk of SCA of
0.5 to 1.0 per 100 000 (or 1 per 200 000 to 1 per 100 000) children and young adults is used for
calculations in the present statement. This figure will likely overestimate the incidence of SCA, particularly
in elementary school children and adolescents who do not participate in athletics.21
As in an adult, if a child develops SCA caused by VF or pulseless (rapid) VT, immediate bystander CPR
and early defibrillation are needed. AEDs are computerized defibrillators designed for use by lay rescuers
to treat SCA. The AED provides voice and visual prompts to guide the rescuer. When attached with
adhesive pads to an unresponsive victim in cardiac arrest, the AED analyzes the victim’s heart rhythm,
determines if a shock is needed, charges to an appropriate shock dose, and prompts the rescuer to
deliver a shock. The AED delivers a shock only if VF or rapid VT is present.
The US Food and Drug Administration has now cleared several AEDs for use in children younger than 8
years of age. Two of these devices have been shown to accurately identify VF and rapid VT in young
children and are also accurate in identifying pediatric rhythms that do not require defibrillation.32,33R33-
141303 When used with a designated pediatric pad-cable system, these AEDs deliver an energy dose
that is smaller than that delivered with adult pads. The AHA2 and the National Association of EMS
Physicians4 state that AEDs may be used with CPR for treatment of prehospital cardiac arrest (victims
who are unresponsive, with no breathing and no signs of circulation) in children 1 to 8 years of age. The
AHA continues to recommend the use of CPR with AEDs for treatment of cardiac arrest in children 8 years
of age and older and in adults.34
Life-Threatening Emergencies in Adults
Noncardiac Life-Threatening Emergencies in Adults
In developing the 2000 international guidelines for CPR and emergency cardiovascular care,11 the AHA
and the International Liaison Committee on Resuscitation (ILCOR) identified the leading causes of death
in persons 25 to 64 years of age. The 10 leading causes of death are malignancy, heart disease,
unintentional injury, suicide, stroke, diabetes, liver disease, human immunodeficiency virus (HIV),
respiratory disease (bronchitis, emphysema, and asthma), and homicide. The leading causes of work-
related fatalities are transportation incidents (41%); assaults and violence (20%); contacts with objects
and equipment, including poisons (16%); environmental exposure (12%); falls (10%); and fires and
explosions (3%).10,11R11-141303
Adult workplace emergencies are likely to be representative of life-threatening emergencies among adults
who work in schools. Rescuers responding to these emergencies must recognize the condition, notify the
EMS system when appropriate, and provide basic first aid until EMS providers arrive. First aid rescuers
must know the general principles for all emergencies, such as how to ensure scene safety, how to assess
responsiveness, how to use personal protective equipment when in contact with blood or other body
fluids, when and how to phone the EMS system, and when it is acceptable to move a victim. In addition, as
noted above, first aid rescuers must be able to control bleeding, recognize and treat shock, immobilize the
spine, warm hypothermia victims, cool heatstroke victims, detect and treat hypoglycemia, support the
airway, and provide CPR and use an AED when needed.
SCA in Adults
SCA is a leading cause of death for adults =" src="/math/ge.gif" border=035 to 40 years of age and is the
most common cause of death for those >45 years of age. In the United States each year, SCA occurs with
an estimated frequency of 1 per 1000 persons =" src="/math/ge.gif" border=035 years of age per year.34–
37R35-141303R36-141303R37-141303 These statistics can be used to estimate the risk of adult SCA for
any location on the basis of the number of adults aged 35 and older typically present at that location and
the number of hours they are present at that location per year (see Appendix 1). Note that the risk of SCA
in adults is 100 to 200 times the estimated risk in children and adolescents and those under 35.21,24–
26R24-141303R25-141303R26-141303
VF and, much less frequently, pulseless VT are the most common abnormal heart rhythms that cause
SCA in adults, although they are not the only rhythms that cause cardiac arrest.31 VF and pulseless VT
are treated with a defibrillator that delivers a shock to the heart. This shock briefly "stuns" the heart,
eliminating the abnormal rhythm and allowing the heart’s normal rhythm to resume.
Victims of SCA due to VF/VT can survive if bystanders and EMS providers act quickly. Bystanders must be
able to recognize cardiac arrest, phone the EMS system, perform CPR, and use the AED. The AHA has
depicted these rescue steps of early recognition, early access to the EMS system, early CPR, and early
defibrillation as links in the Adult Chain of Survival38:
1. Early recognition of the emergency and early activation of the EMS system
2. Early CPR
3. Early defibrillation
4. Early advanced life support
Studies have shown that immediate bystander CPR and defibrillation within minutes provide the best
chance of survival from sudden VF cardiac arrest in adults. Survival rates of 50% to 74% have been
reported when adult victims of VF SCA collapse in front of witnesses and receive immediate bystander
CPR plus defibrillation within 3 to 5 minutes of collapse. These adult survival rates have been documented
in settings such as airports,39 commercial airlines,40,41R41-141303 casinos,42 and communities with
police who are trained and equipped to respond to SCA.43–46R44-141303R45-141303R46-141303

   Current Level of School Preparation for Medical Emergencies

School nurses, teachers, athletic trainers, coaches, and staff are responsible for the physical well-being of
a large portion of the nation’s children for many hours each day. Schools now employ fewer nurses, and
school nurses often rotate between schools, so some schools are without professional medical coverage
for hours or days every week.7 Much of the responsibility for the physical care of students during a typical
school day now rests with teachers, athletic trainers, coaches, and staff. In a random survey of elementary
and high school parents and teachers in the Midwest, 80% of parents indicated that they assumed that
teachers were adequately trained in first aid and CPR, but one third of the teachers surveyed had no
training in first aid, and 40% had never completed a course in CPR.7 A survey in New Mexico confirmed
that few school nurses and staff had any emergency training.8
In a survey of all high schools in Washington State, 80% of teachers thought that CPR training was
important, yet 35% of schools provide no CPR training for students.47 When the schools were asked to
identify factors that would be most likely to encourage schools to offer CPR training for students, 24%
indicated that funding would be helpful, and 17% indicated that a requirement or credit for CPR training
would encourage CPR training.47

   School Medical Emergency Response Plan: Recommended Elements

The goal of the Medical Emergency Response Plan for Schools initiative is to encourage every school to
develop a program that reduces the incidence of life-threatening emergencies and maximizes the chances
of intact survival from an emergency. Such a program will have the potential to save the greatest number
of lives with the most efficient use of school equipment and personnel.
The authors and endorsing organizations of the present statement recommend the following core
elements of a school medical emergency response plan:
1. Effective and efficient communication throughout the school campus: Establish a rapid
communication system linking all parts of the school campus, including outdoor facilities and practice
fields, to the EMS system. Establish protocols to clarify when the EMS system and other emergency
contact people should be called. Determine the time required for EMS response to any location on
campus and establish a method to efficiently direct EMS personnel to any location on campus. Create a
list of important contact people and phone numbers with a protocol to indicate when each person should
be called. Include names of experts to help with postevent support.
2. Coordinated and practiced response plan: Develop a response plan for all medical emergencies in
consultation with the school nurse, the school or school athletic team physicians, athletic trainers, and the
local EMS agency, as appropriate. EMS and emergency dispatchers (9-1-1 centers) should be made
aware of the type of rescue equipment available at the school and its location. Practice the response
sequence at the beginning of each school year and periodically throughout the year, and evaluate and
modify it as needed.
3. Risk reduction: Prevent injuries through safety precautions in classrooms and on the playground.
Identify students, faculty, and staff with medical conditions that place them at risk for development of life-
threatening conditions, and train and equip personnel to provide the appropriate response for those
conditions.
4. Training and equipment for first aid and CPR: Ensure that many teachers are trained as CPR and
first aid instructors. Train school staff and graduating high school students in CPR. Teachers and staff
trained in first aid should, at a minimum, be equipped and able to give first aid for the following life-
threatening emergencies until EMS rescuers arrive:
a. Severe breathing problems, including asthma, choking, and anaphylaxis (severe allergic reaction)
b. Chest pain and heart attack
c. Diabetes and low blood sugar
d. Stroke
e. Seizure
f. Shock
g. Bleeding
h. Head and spine injury
i. Broken bones
j. Burns
k. SCA
l. Temperature-related emergencies (heatstroke and hypothermia)
m. Poisoning
5. Implementation of a lay rescuer AED program in schools with an established need: If the school
determines that a lay rescuer AED program is needed, school administrators and medical personnel
should include the AED program in the school medical emergency response plan and practice and
evaluate response to SCA using the AED. EMS and 9-1-1 centers should be notified of the specific type of
AED and the exact location of the AED on the schoolgrounds. Rescuers who are unfamiliar with the school
can call 9-1-1 and receive instructions from 9-1-1 dispatchers to find and use the AED. AED programs
should have the following elements:
a. Medical/healthcare provider oversight
b. Appropriate training of anticipated rescuers in CPR and use of the AED
c. Coordination with the EMS system
d. Appropriate device maintenance
e. Ongoing quality improvement program
A medical emergency response plan must start with development of a good system of communication. It
also requires development and coordination of a planned and practiced response, risk reduction, and
training and equipment.
Effective and Efficient Communication
An effective emergency response plan begins with establishment of rapid, effective communication to and
from every location on the school campus. This network can be built with cellular telephones, walkie-
talkies, alarms, or intercom systems to establish contact with a central location that is responsible for the
EMS call. Several such systems may work, as long as the EMS system can be contacted immediately and
directed to the site of any emergency without delay. Critical delays will result if teachers or coaches must
send a runner from a distant practice field or track to the school office, so this method of communication is
not recommended. The local EMS system may be able to provide valuable input in development of the
plan.
Every school district and each school should identify persons who will be authorized and trained to make
decisions when health emergencies occur. The names, telephone numbers, and locations of these
persons should be provided to all staff members, with a protocol indicating when each authority should be
called.
All school staff should be taught when to telephone the EMS service (phone 9-1-1), when to phone other
school or medical personnel, where to find the emergency equipment, how to clear crowds, and how to
direct arriving EMS personnel to all sites on campus. These efforts will ensure that the entire staff is
engaged in the response plan.
The lay press has reported unfortunate delays in emergency response when student calls for help are
dismissed as pranks. The school must sensitize teachers, staff, and students to the gravity of reports of
emergencies. Student reports of emergencies must be taken seriously, and disciplinary consequences
must follow any false claims.
Coordinated and Practiced Response Plan
Plan Development
The school nurse and school or team physicians and athletic trainers should be involved in development
of the medical emergency response plan. The plan should specify their participation in the emergency
response and in documentation, evaluation, and postevent support of students, teachers, and staff.
The school should coordinate the plan with the local EMS agency and integrate it with the local EMS
system. School administrators should invite input from both the emergency medical dispatch system and
the EMS system that provides responding units to the school. The local EMS agency should be
encouraged to conduct an on-site "preincident" visit to identify problems, such as restrictive passages
through the school parking lot or buildings or any areas that are inaccessible to a crew in an ambulance.
Written notification protocols should list the appropriate contact people and their contact telephone
numbers and should specify when parents, school district personnel, and the EMS system should be
contacted. Forms should be available to document the details of an emergency event. A complete
Emergency Information Form should be available for reference during emergencies involving children with
special healthcare needs.
The school should give a copy of the final emergency response plan to the local EMS system and local
EMS dispatcher. This plan should include the location and type of emergency equipment. The school
should notify the local fire/emergency rescue agency if any faculty, staff, or students at the school are
dependent on mechanical ventilation or other electrical equipment so the agency is prepared to provide
support in the event of a power failure or other emergency. National crisis plans now require schools to
keep detailed floor plans and maps of the school property for use in emergencies. Much of this
information can be entered into computer-aided dispatch systems at the 9-1-1 dispatch center and linked
to the school’s address and telephone numbers. Entering this information will permit 9-1-1 dispatchers to
have immediate access to this information during the emergency call.
Plan Practice and Evaluation
Each school should practice and evaluate the response plan with participation of the school nurse, school
or team physicians, athletic trainers, and the local EMS system. This plan should target a collapse-to–EMS
call time of 1 minute, provision of first aid and CPR when appropriate, and a collapse-to–first shock time of
<3 minutes for SCA if an AED program is on site.34
Designated rescuers should participate in unannounced practice drills on a regular basis (eg, at the
beginning of every school year and repeated during the school year) to promote an efficient, organized,
and timely response to life-threatening medical emergencies anywhere on the schoolgrounds. These
practice drills should include real-time participation by students, staff, and faculty who feign emergency
conditions or participate as members of the response or communication team. The drill should use
manikins to simulate victims in cardiac arrest. The AHA has created scenario cards that may be used for
these practice drills. The scenario cards are available in the AHA instructor materials.48 Scenarios are
also in the ARC first aid/CPR/AED program instructor materials.
During each practice drill, an observer should record the following:
1. Critical time intervals: time from development of the emergency to 9-1-1 call; time from development of
the emergency to administration of first aid; time from collapse to bystander initiation of CPR (if indicated);
time from collapse in cardiac arrest to delivery of first shock (if an AED program is in place); and time to
arrival of EMS personnel at the victim’s side.
2. Availability and function of emergency equipment at the school.
After each drill, review performance of each component of the plan, and revise the school emergency
response plan as needed to improve performance and efficiency.
When a life-threatening medical emergency does occur at the school, administrators should hold a
postevent meeting of all involved personnel. This meeting should be scheduled within a few days of the
emergency and should provide the opportunity for a frank discussion of what worked, what didn’t work,
and how to improve the response plan. This will enable revision of the response plan to better serve the
next emergency.
Postincident counseling should be available to staff and students whenever a fatal or near-fatal event
occurs at the school. Most school districts have designated counseling staff to handle such needs. The
school supervisor should identify resource personnel before an emergency arises and should have
contact numbers for use in the event of an emergency. The local children’s hospital, medical center,
community mental health agency, or local EMS agency may be able to provide names of experts.
Risk Reduction
The Medical Emergency Response Plan for Schools should strengthen each link in the Chain of
Survival. The first link in the AHA Infant and Child Chain of Survival is prevention of life-threatening
events through education about injury prevention and identification, evaluation, and support of children at
risk. Some injuries that occur on schoolgrounds result from high-risk behavior that begins at home.
Schools should provide injury prevention information to children and families about the importance of age-
appropriate restraint devices in automobiles, use of bicycle helmets, use of smoke detectors, and use of
trigger locks and lock boxes for firearms stored at home.
Injury prevention in schools requires proper equipment maintenance and supervision of students during
shop and laboratory classes, playground time, physical education classes, and team sports. Students and
teachers should wear proper safety gear during shop, laboratory, and physical education classes. All
class equipment should be kept in good working order and any dangerous or flammable chemicals stored
in locked cabinets.
The ground surface under swing sets, climbing bars and slides, and gymnastic equipment should be
sufficiently cushioned to reduce impact and prevent injuries. All playground equipment should be
constructed without sharp edges and should be properly maintained.
As noted above, the school should be aware of any children with medical conditions that may have life-
threatening complications. If a student has a health problem that could be life threatening, the school
nurse should develop an emergency care plan for that child. The child’s teachers and the school nurse
should be prepared to activate that plan when needed. The school should ask the parents to consult the
child’s physician to determine if the school should maintain an extra supply of medications (eg,
bronchodilator administered by metered-dose inhalers with spacers for children with severe asthma) for
use during emergencies or exacerbations. The school must be in compliance with state laws and
regulations and school board policies for use of these medications. If appropriate, information about the
child’s condition should also be conveyed to the local EMS agency.
Routine medical care of many conditions, such as asthma, can modify the course of the disease and make
acute exacerbations less likely. Teachers should consult the child’s parents and physician to identify and
eliminate factors in the classroom or school environment that may act as triggers for asthma or severe
allergic reactions.6
Training and Equipment for First Aid and CPR
As part of the Medical Emergency Response Plan, the school nurse and physician, the athletic trainer,
and several faculty members should be trained in and equipped to provide first aid and CPR. Ideally, the
school should establish a goal to train every teacher in CPR and first aid and train all students in CPR. All
students, faculty, and staff should know how to access the EMS system. The school should maintain a first
aid kit, and school staff must know where emergency equipment is stored.
The authors and endorsing organizations of this statement have not specified the number of teachers and
staff to be trained in first aid and CPR at each school. There should be a sufficient number of trained
faculty, staff, and students, however, to ensure that a trained rescuer can get the appropriate equipment
and reach any area of the campus within 90 seconds of the onset of the emergency. Persons trained in
CPR and first aid should therefore be carefully selected on the basis of their likely location on the school
campus each day, their typical responsibilities, and their likely response interval in the event of an
emergency. An office assistant may be able to respond more quickly to an emergency than a teacher who
is often off campus for meetings. In a typical school, at least 2 teachers and 2 alternate rescuers will likely
be required to ensure coverage for every location and every school day. The school should also evaluate
the number of students and adults present on schoolgrounds during afterschool activities, and the plan
should cover these time periods if needed.
Training in First Aid and Universal Precautions
All school nurses, physicians, athletic trainers, and several faculty and staff should be trained and
equipped to provide first aid because immediate first aid can prevent a life-threatening problem from
becoming a fatal one. Potential rescuers must be able to recognize and provide initial treatment for
breathing emergencies such as choking, severe asthma, or severe allergic reaction; injury emergencies
such as burns, shock, head or spinal cord injury, or bleeding; neurological emergencies such as seizures
and stroke; temperature-related emergencies such as heatstroke and hypothermia; and poisoning.
Certified athletic trainers are educated to care for student athletes with sports-related injuries and
emergencies.5 Coaches should be trained to provide CPR (with an AED if indicated) and first aid for
common and life-threatening sports-related emergencies.49
Every school should comply with precautions to minimize the risk of blood-borne pathogens. In some
states, public schools must comply with the Occupational Safety and Health Administration (OSHA)
standards with regard to blood-borne pathogens.
Several courses have been developed in recent years to provide training in first aid, including precautions
to minimize risk of blood-borne pathogens. The AHA and ARC have developed first aid courses to teach
these essential assessment, knowledge, and first aid skills to workplace rescuers.50 The University of
Connecticut College of Continuing Studies developed the School Nurse Emergency Medical Services for
Children (SNEMS-C) Program.51 The National Standards for Athletic Coaches provide information needed
by coaches to deal with sports-related injuries.49 Visual aids such as first aid posters can be displayed in
conspicuous places to remind faculty, staff, and students of critical first aid and CPR skills.
Training in CPR
CPR training is important for several reasons. First, rapid bystander CPR, particularly provision of rescue
breathing, may prevent breathing problems and other emergencies from progressing to cardiac arrest.
Second, CPR has been shown to improve the chance of survival in adults and children with cardiac arrest.
In one recent study of children who required CPR in the out-of-hospital setting, 1 child was resuscitated by
bystander CPR alone for every 7 children who required CPR by EMS personnel.52,53R53-141303
Immediate bystander CPR for adults with SCA can double survival.40
Because bystander CPR is so critical in improving survival from SCA, the AHA recommends that all
high school students be trained in CPR. To facilitate this training, the AHA and ARC developed school
CPR courses with course materials tailored for teaching children in a classroom setting.54 The Maternal
and Child Health Bureau has also developed a course to teach CPR in schools.55 Such training should
increase the likelihood of immediate initiation of bystander CPR for victims of SCA and should contribute
to improved survival rates. CPR training may also have less quantifiable benefits. For example, CPR
training implies an underlying commitment to fellow citizens and may encourage and model a willingness to
provide assistance to victims of medical emergencies.
Equipment
Equipment is an important part of any medical emergency response plan, beginning with a first aid kit and
CPR barrier devices and may include an AED. First aid and CPR-AED equipment should be carefully
selected on the basis of the types of emergencies likely to develop at the school. For example, if football,
gymnastics, or diving events take place on campus, a backboard with restraints should be available to
immobilize an athlete with suspected spine injury.
Epinephrine can be lifesaving for victims with anaphylaxis (severe allergic reaction), such as that resulting
from a bee sting, a severe food allergy, or latex allergy. Some states and EMS systems encourage the use
of epinephrine autoinjectors for emergency treatment of severe allergic reactions. If state and EMS
regulations allow, these autoinjectors can be included in the school’s emergency equipment, and staff
should be trained in their use. A physician’s prescription is required to purchase autoinjectors. To check
state regulations about epinephrine autoinjectors, contact the AHA at 1-888-277-5463.
A physician may determine that other medications, such as bronchodilators (medicines that open
narrowed airways) administered by metered-dose inhalers with spacers, oxygen, and glucose or glucagon
(a rapid-acting hormone for treatment of severe low blood sugar), should be kept at the school for at-risk
students or staff. In this case, the student’s family or a member of the school staff is responsible for
providing the medication. A school nurse must be regularly available to give medications or delegate
administration of medications if allowed by local law and school district policy.
School personnel first aid training includes recognition of low blood sugar (hypoglycemia) and
administration of a source of rapid-acting sugar. The parent of the diabetic child is responsible for
providing the school with such foods as fruit juice, packets of sugar, or a (nondiet) soft drink to be
administered by trained staff if the child shows signs of hypoglycemia.
Any equipment is useless unless it is readily accessible in an emergency and rescuers are appropriately
trained to use it. First aid and resuscitation equipment should be placed in a central, highly visible, and
accessible location near a telephone, and all school faculty, staff, and students should know where the
equipment is stored. If the school is large, it may be necessary to keep duplicate equipment in several
areas. Because injuries are most likely to occur during athletic activities, the athletic facilities should be
considered high-priority areas for placement of equipment such as the first aid kit and spine backboards.
General emergency equipment should not be placed in a locked office or cabinet because this might delay
emergency care. Unfortunately, accessibility will provide opportunities for theft or vandalism of equipment.
This problem has been solved in many schools and public places such as airports by the use of mounted
cabinets with audible alarms that sound when the cabinet door is opened. These cabinets cost $250 to
$500.
If medications such as epinephrine autoinjectors, bronchodilators, and glucagon are included in the
school medical emergency response plan or a child’s emergency care plan, these items should be kept in
a location that is readily available to trained rescuers and the school nurse but not accessible by students
and the general public. If a student has a healthcare problem that may require the use of emergency
medications, the school nurse must develop a plan to make the medication available to the child when
needed.
EMS and 9-1-1 centers must know in advance where emergency equipment is kept on school property.
This can prevent failure to use available equipment (such as an AED) because responders are unaware
of the existence or location of the equipment. If the 9-1-1 center knows where emergency equipment is
located on the school grounds, the dispatcher can tell the rescuer where to find the equipment and can
instruct rescuers in the use of the equipment before the arrival of EMS personnel.
Implementation of a Lay Rescuer AED Program in Schools With a Documented Need
To determine the need for an AED program at any location, the ECC Guidelines 200034 recommend
consideration of lay rescuer AED program implementation in locations with at least one of the following
characteristics:
1. The frequency of cardiac arrest events is such that there is a reasonable probability of AED use within
5 years of rescuer training and AED placement. This probability is calculated on the basis of 1 cardiac
arrest known to have occurred at the site within the last 5 years, or the probability can be estimated on the
basis of population demographics (see Appendix 1); or
2. There are children attending school or adults working at the school who are thought to be at high risk
for SCA (eg, children with conditions such as congenital heart disease and a history of abnormal heart
rhythms, children with long-QT syndrome, children with cardiomyopathy, adults or children who have had
heart transplants, adults with a history of heart disease; etc); or
3. An EMS call–to-shock interval of <5 minutes cannot be reliably achieved with conventional EMS
services and a collapse-to-shock interval of <5 minutes can be reliably achieved (in >90% of cases) by
training and equipping laypersons to function as first responders by recognizing cardiac arrest, phoning 9-
1-1 (or other appropriate emergency response number), starting CPR, and attaching/operating an AED.
When funds are limited, but there is a desire to establish some AED school programs, priority should be
given to establishing programs in large schools, schools used for community gatherings, schools at the
greatest distance from EMS response, and schools attended by the largest number of adolescents and
adults (eg, high schools and trade schools).
The 5 components of an AED program are
1. Medical/healthcare provider oversight
2. Appropriate training of anticipated rescuers in CPR and use of the AED
3. Coordination with the EMS system
4. Appropriate device maintenance
5. An ongoing quality improvement program to monitor training and evaluate response with each
use of the device
If an AED program is established at the school, the AED should be placed in a central location that
is accessible at all times and ideally no more than a 1- to 11/2-minute walk from any location. The
device should be secure and located near a telephone (eg, near the school office, library, or gymnasium)
so that a rescuer can activate the EMS system and get the AED at the same time. The EMS system should
be notified of the establishment of the AED program, and the emergency medical dispatcher should know
the specific type of AED at the school and where it is located. Several staff members should be trained in
both CPR and use of the AED.
Recent federal legislation provides guidance for AED programs in schools. HR 389-PL 108-41 enabled
the creation of an information clearinghouse with funds from the AED program in the Public Health
Security and Bioterrorism Response Act (PL 107-188). The new law allows creation of a national resource
center to provide schools with information and technical guidance to set up AED programs, giving schools
access to the appropriate training, fundraising techniques, and other logistics required to make such
programs successful. The national resource center is modeled after Project ADAM (Automatic
Defibrillators in Adam’s Memory), a joint venture between the Children’s Hospital of Wisconsin and David
Ellis, a friend of the project’s namesake, Adam Lemel, who collapsed and died during a high school
basketball game. Senate Bill 231 is a companion measure. For information about the clearinghouse, visit
http://healthlink. mcw.edu/article/962141848.html. For information about establishing an AED program, call
the AHA (1-877-242-4277), or visit the AHA website at http://www.americanheart.org/cpr.

   Legislative Mandates and Funding for School Medical Emergency Response Plan

Legislative efforts to save the lives of children who develop life-threatening emergencies at schools should
support an approach that is most likely to save the greatest number of lives. A planned program should be
required, as should appropriate training and equipment.
Unfunded legislative mandates, particularly those that address the purchase of equipment rather than
programs of planned response, will limit effectiveness and place a substantial burden on school budgets.
Many school budgets are already stretched to provide basic education, achieve student test score goals,
and meet the needs of a wide range of students, including those with special healthcare and learning
needs. Unfunded mandates for emergency care in schools are likely to be met with minimal effort that
does not include the development of planned and practiced responses and the training and retraining that
are most likely to save lives. Policymakers must work with schools to ensure that long-term solutions are
enacted to be sure that programs are sustained indefinitely.
Local and state policymakers should support an immediate response to life-threatening medical
emergencies with the following priorities for policy and appropriations:
1. Establishing an efficient and effective campus-wide communication system for each school
2. Developing a coordinated and practiced medical emergency response plan with the school nurses,
physicians, athletic trainers, and the EMS system, with appropriate evaluation and quality improvement
3. Reducing the risk of life-threatening emergencies by identifying students at risk and ensuring that each
has an individual emergency care plan and by reducing the risk of injury and disease triggers at the school
4. Training and equipping teachers, staff, and students to provide CPR and first aid
5. Establishing an AED program in those schools with a documented need
Note that some schools throughout the United States have implemented some components of the medical
emergency response plans without the use of public funds. Fundraising for such activities can take many
different approaches, including sponsorship by local organizations (eg, Rotary Club, Parent-Teacher
Association) and student activities (eg, car washes, bake sales). Such programs do not ensure
predictable coverage for the greatest number of students, however.

   Conclusions

On any given day, as much as 20% of the combined US adult and child population can be found in
schools. Life-threatening emergencies in schools are relatively uncommon, but when they do occur, they
require a planned, practiced, and efficient response with provision of first aid and possible CPR and use
of an AED. To maximize survival from a life-threatening emergency, schools must develop a medical
emergency response plan designed to provide appropriate therapy within the first minutes of the
emergency. The medical emergency response plan includes (1) creation of an effective and efficient
campus-wide communication system; (2) coordination, practice, and evaluation of a response plan with
the school nurse and physician, athletic trainer, and local EMS agency; (3) risk reduction; (4) training in
and equipment for CPR and first aid for the school nurse, athletic trainers, and teachers and CPR training
for students; and (5) in schools with a documented need, establishment of an AED program.

   Footnotes

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest
that may arise as a result of an outside relationship or a personal, professional, or business interest of a
member of the writing panel. Specifically, all members of the writing group are required to complete and
submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or
potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating
Committee on November 4, 2003. A single reprint is available by calling 800-242-8721 (US only) or writing
the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for
reprint No. 71-0273. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax
413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kgray@lww.com. To
make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
*From the following organizations: American Heart Association, American Academy of Pediatrics, American
College of Emergency Physicians, American National Red Cross, National Association of School Nurses,
National Association of State EMS Directors, National Association of EMS Physicians, National Association
of Emergency Medical Technicians, and the Program for School Preparedness and Planning, National
Center for Disaster Preparedness, Columbia University Mailman School of Public Health. This statement
was also reviewed by the Centers for Disease Control Division of School and Adolescent Health.
Simultaneous publication: This Statement is being published simultaneously in the journals Circulation,
Annals of Emergency Medicine, and Pediatrics RFN1RFN1