Cardiopulmonary Resuscitation Training in Sport Universities: An Italian Survey

doi:10.4236/ape.2013.33022

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Advances in Physical Education

2013. Vol.3, No.3, 131-135

Published Online August 2013 in SciRes (http://www.scirp.org/journal/ape) http://dx.doi.org/10.4236/ape.2013.33022

Cardiopulmonary Resuscitation Training in Sport

Universities: An Italian Survey

Andrea Scapigliati1, Saverio Giampaoli2, Alessia Marsili2,

Federica Valeriani2, Vincenzo Romano Spica2*

1Catholic University of the Sacred Heart, Rome, Italy

2University of Rome “Foro Italico”, Rome, Italy

Email: *[email protected]

Received December 17th, 2012; revised February 7th, 2013; accepted February 14th, 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-

vided the original work is properly cited.

Background: Physical activity is associated to an increased risk of sudden cardiac death (SCD). Together

with primary prevention, prompt recognition and early management of SCD are crucial in order to im-

prove survival rate. During their duty, sport trainers and teachers can play a key role in secondary preven-

tion of cardiac arrest provided they have received an appropriate training in Cardiopulmonary Resuscita-

tion (CPR) during their curricular study. This is usually achieved through a Basic life Support and Defi-

brillation (BLS-D) Course which in Italy formally enables to Automated External Defibrillator (AED) use.

Objective: To investigate the presence, the type and the diffusion of cardiopulmonary resuscitation train-

ing in Sport and Exercise Sciences Universities in Italy. Design: Descriptive survey research design was

adopted for the study. Setting: The study sample consisted of 32 Italian Universities with Bachelor and

Master-Level Degrees in Sport and Exercise Sciences. Methods: Teaching secretary or directly deans/

course presidents were contacted by email or telephone in order to collect information on the availability

of BLS-D courses for Sport and Exercise Sciences students during the academic year 2010-2011. Results:

The compliance to the survey has been >93%. Only a reduced number of the contacted Universities of-

fered dedicated courses of Cardiopulmonary Resuscitation with license to Defibrillation according to cur-

rent local regulation. Conclusion: The described situation shows a limit in the generation of a sport train-

ers’ category highly specialized in cardiac and respiratory emergencies: only 6 Universities organize

BLS-D training with official certification.

Keywords: Basic Life Support; Defibrillation; Cardiopulmonary Resuscitation; Sudden Cardiac Death;

Cardiac Arrest; Sport; University; Public Health

Introduction

It is well recognized that regular physical activity reduces co-

ronary heart disease events (Nam, 2011). However, exposure to

vigorous exercise can increase the risk of sudden cardiac death

(SCD) up to three times as higher in competitive athletes as in

general population, acting as a trigger of cardiac arrest (CA) on

different age-related underling causes (American College of

Sports Medicine & American Heart Association, 2007; Thomp-

son et al., 2007; Batra & Balaji, 2012). Furthermore, sport prac-

tice can be associated with chest trauma (i.e., commotio cordis),

other accidents such as drowning, or behaviors (drug abuse and

doping) which are all potential causes of CA (Solberg et al.,

2011). Our knowledge on epidemiology of sport-related CA is

limited by difficult and discrepant data collection varying on

geographical basis (Borjesson & Pelliccia, 2009; Webner et al.,

2012). From a European perspective, in the restricted area of

Veneto Italian region, where a precious prospective registry of

CA in young athletes (≤35 years) is available, the SCD inci-

dence was 3.6/100.000 participants per year (Corrado et al.,

2006). In a recent France national survey based on ambulance

service data and media reports (susceptible of underreporting

bias), the overall incidence of sport-related sudden death in the

general population was 4.6 per million population per year,

90% during recreational sport activity and 6% in young com-

petitive athletes (Marijon et al., 2011). In all studies an over-

whelming male predominance was found. These data suggest

that CAs in competitive and top athletes are not only the more

visible aspect of a hidden but larger and more widespread phe-

nomena. Recent episodes of CA during excellence sport compe-

titions raised old questions on prevention and treatment of

sport-related CA considering the large population which prac-

tice physical activity at any level. Mandatory medical screening

as a tool of primary and secondary prevention has had a dra-

matic effect in the last three decades in decreasing SCD rate

among competitive athletes in Italy (Corrado et al., 2009; Corra-

do et al., 2012). However, once CA has occurred for any reason

(screening failure, unpredictable precipitating cause, fatal acci-

dent), bystander Cardiopulmonary Resuscitation (CPR) toge-

ther with Automatic External Defibrillator (AED) use is recog-

nized as the best intervention for early treatment of CA and is

associated with higher survival rate compared with no early

CPR, CPR alone without defibrillation and Emergency Medical

*Corresponding author.

A. SCAPIGLIATI ET AL.

System (EMS) arrival (Koster et al., 2010). Therefore, it is like-

ly that public interventions aimed to a larger diffusion of CPR

training and AED deployment in sport venues can act as an ef-

fective tertiary prevention strategy. A recent Italian law impos-

es the presence of AED in sport facilities (Republic of Italy,

2012). Since sport trainers and teachers can play a crucial role

in prevention especially in recreational sport (where medical

screening is far less implemented) and are likely to be among

bystander rescuers in case of CA, a specific curricular educa-

tion program on SCD prevention and treatment could be effec-

tive in reducing sport-related unexpected deaths.

In Italy, professional sport trainers and teachers have usually

got a degree in Universities with Departments of Sport and

Exercise Sciences (SES). In this context, dedicated courses of

Basic Life Support and Defibrillation (BLS-D) with a specific

focus on sport setting, can provide students with the ability to

recognize and treat CA as well as altered level of consciousness

and respiratory emergencies, with specific skill to operate an

AED. In the present paper we investigated the diffusion of

BLS-D training courses in Italian Universities with Bachelor

and Master-Level Degrees in SES. The reported data are the re-

sult of a survey conducted in the Academic Year 2010-2011.

Methods

Thirty-two Italian Universities (Figure 1) with Bachelor and

Master-Level Degrees in SES (13 in the north, 9 in the centre,

and 10 in the south of the Country) had been identified through

the Registry of the Italian Ministry of Education, Research and

University and contacted electronically or by telephone in 2011

and 2012 for an interview. Questions were addressed to teach-

ing secretary or directly to deans/course presidents. The inter-

view was aimed to know if BLS-D courses dedicated to SES

students were available in Academic Year 2010-2011 and, when

present, if training was mandatory. Since Italian regulation cur-

rently allow the use of an AED by non-healthcare professionals

(lay persons) only after a formal training with certification (va-

lid for 1 year), a specific question addressed this information.

The items of the survey are summarized in Table 1. BLS-D

course was intended as including frontal lessons on SCD in

sport, CA, CPR and AED use together with skill teaching on

mannequins with CA simulation scenarios and AED training

devices. For this kind of course 4 - 6 hours are traditionally re-

quested with an instructor/students ratio of 1/5 - 6. Data collec-

tion was independently checked by two different researchers

and where information was missing Universities were contacted

again. If data interpretation was discrepant, discussion in pres-

ence of a third researcher allowed a final agreement. The col-

lected data were processed and presented in this paper in a ano-

nymous way.

Results

Survey Categori es

Thirty Universities out of 32 included in the interview pro-

vided the requested information (compliance to the survey of

>93%). According to the survey items (Table 1), the collected

data were summarized in six categories:

1) MH (Mandatory & Habilitation) Universities with man-

datory BLS-D training and final certification for AED use in

the Country;

2) OH (Optional & Habilitation) Universities with optional

Figure 1.

Distribution on the national land of the universities involved in the sur-

vey.

Table 1.

Items of survey.

Questions Answers

BLS-D course training Presence/Absence

Level of the degree involved Bachelor/Master, both

Teachers involved Relevant subject

Attendance Mandatory/Optional course,

number of students attending

AED use Formal/Informal certification

Certification agency Emergency Medical System

(EMS)/Scientific organization

Other kind of training No formal BLS-D course, other

BLS-D training and final certification for AED use in the Coun-

try;

3) MW (Mandatory Without habilitation) Universities with

mandatory BLS-D training but without final certification for

AED use in the Country;

4) OW (Optional Without habilitation) Universities where

the training was neither mandatory nor with certification;

5) GI (General Information) Universities were students re-

ceived only general information on CPR without training;

6) N/A (Not Available) University without any kind of edu-

cation on the subject.

Survey Outp ut

As showed in Figure 2, the survey found that in the Aca-

demic Year 2010-2011, only one Italian University with De-

partment of SES had mandatory training in BLS-D with final

132

A. SCAPIGLIATI ET AL.

n = 30

Figure 2.

Results of the survey by categories. MH (Mandatory

& Habilitation), (1/30). OH (Optional & Habilitation),

(5/30). MW (Mandatory Without habilitation), (5/30).

OW (Optional Without habilitation), (3/30). GI (Gen-

eral Information), (6/30). N/A (Not Available), (10/

30).

certification for AED use in the Country (1/30, 3%). Five Uni-

versities (5/30, 17%) had a certified but optional BLS-D course

involving a range of approximately 20 - 100 students per year.

Overall Universities without AED use certification accounted

for 27% of the total, 5/30 with mandatory and 3/30 with optio-

nal BLS-D Course respectively. The rest of the Universities re-

sponding to the survey provided general information on CPR as

part of other courses (6/30), or had no official lessons covering

this issue (10/30). Among Universities with BLS-D courses and

AED use certification, the average numbers of participating stu-

dents was 36 (for this question the compliance of the survey

was 33%). The majority (>62%) of Universities offering the

BLS-D training organized courses both at the Bachelor and Ma-

ster-Level Degree. All the University in the MH and OH cate-

gories were localized in the north and in centre of the Country

(Figure 3). Where present, certification was provided by Emer-

gency Medical System in 4 cases, from National Resuscitation

Council in 2 cases.

Discussion

The National Context

The main result of the present survey is that only a minority

of students attending Italian Universities with Department in

SES are provided with formal training in CPR and AED use.

Furthermore, no uniformity of teaching is present among Uni-

versities in the Country, reflecting a lack of common strategy.

The presence of CPR and AED courses seems to depend more

on local initiative more than on public health and teaching na-

tional planning. These findings can be explained primarily with

the absence of a National regulation on education strategy and

University teaching about this specific topic. This lack, together

with discrepancies in local resources, can account for regional

differences in BLS/AED training offer along the Country. How-

ever a deeper reason for this inadequate and non homogeneous

frame is probably the poor general awareness about the crucial

role of first responders in the treatment of CA victims.

The Importance of Early Recognition of CA

The well known concept of the Chain of Survival (the inter-

dependent positive effect of a series of consecutive actions such

Figure 3.

Classification of survey results according to land localization of univer-

sities.

as Prevention, Early recognition and Call for help, Early CPR,

Early Defibrillation, Post-resuscitation care) in the context of

sport-related CA can rely on traditional healthcare professionals

(i.e. physicians and EMS) mainly in the very first (i.e. preven-

tion) and late links (i.e. the so called Advanced Life Support,

ALS, usually restricted to the hospital phase of treatment) (Ko-

ster et al., 2010). The central links of the chain (i.e. early CPR

and Defibrillation) are largely dependent on the first witnesses

of CA, their willingness to step in rescue and their skill to per-

form correct actions. Available data in the specific sport context

have proven how CA during sport activities is very often wit-

nessed. As reported in Drezner et al. (2007) survey, 97% of re-

ported CA involving student athletes or older nonstudents in-

volved in school-related sport activities were witnessed, 94%

received bystander CPR in about 1 minute from collapse and

most of them received an AED shock after a short interval from

collapse (<4 minutes). Noteworthy, the first responder was a

nontraditional health professional in the majority of cases (i.e.,

certified athletic trainers, coaches or teachers) when compared

with school physicians and nurses, while EMS personnel were

not on site at CA time in any case. In this series, overall survi-

val to discharge was an outstanding 64% when compared with

data related to out of hospital cardiac arrest in the general po-

pulation (about 10%) (Berdowski et al., 2010). In Marijon et al.

(2011) study, bystander CPR, time from collapse to start CPR

and defibrillation were the most important independent factors

associated with survival. Furthermore, in a wider preventive

strategy of SCD, non-traditionally health-related professionals

can play a two-level role. Together with their role in tertiary

prevention (i.e. treatment of CA once it has occurred), they can

take part to the primary and secondary prevention (i.e. general

and at risk population screening). Since neither ECG at rest nor

exercise testing screening are mandatory in leisure-time sport

activities, especially in middle aged/senior individual, trainers/

coaches/teachers can reinforce the first line screening with tu-

toring intervention, for instance with the administration of a

validated physical evaluation questionnaire such as proposed by

European Association of Cardiovascular Prevention and Reha-

bilitation (Borjesson, Urhausen et al., 2011).

The Importance of Curricular Trainings

Another reasons for poor diffusion of CPR training as found

in this survey could be the lack of widespread and accepted

A. SCAPIGLIATI ET AL.

recommendations on the specific topic. To work effectively, the

Chain of Survival must be based on proper plans and prepared-

ness. Skills acquisition in CPR is not for ever and frequent re-

training is necessary to maintain proficiency as well as equip-

ment (especially AED) needs periodic maintenance. While state-

ments on emergency preparedness and SCD management in

athletic facilities have been published in USA, a recent position

stand from the Sports Cardiology section of the European As-

sociation of Cardiovascular Prevention and Rehabilitation

(EACPR) aimed to fill a current gap about acute cardiovascular

care at sport arenas in Europe (Drezner et al., 2007; Borjesson

et al., 2011). A proper curricular training for SES Universities

should take in account the elements suggested in these state-

ments, enabling students to have an active role in elaborating

and implementing emergency plans in sport venues where they

could work. Specific features of sport-related CA should be co-

vered as well, such as how to deal with frequent seizure-like

activity and pulse/respiration presence (in 50% and 57% of

cases respectively in Drezner et al. (2007) study), a description

of commotio cordis and general information on pediatric CA,

foreign body airway obstruction treatment and rescue lateral

positioning of the victim. In our Institution we aimed to cover

with all these issues through a Course on Medical Emergencies

at Sport Venues including a formal BLS-D Course with AED

use certification. The none uniform distribution of BLS-D

courses, as showed in the results of the survey presented in this

paper, can clearly discriminate some regions (for example south

and islands in Italy) where students did not have the opportu-

nity to obtain a valid training in CRP inside their academic cur-

riculum studiorum. The described situation shows a limit in the

generation of a sport trainers category highly specialized in

cardiac and respiratory emergencies. This can be an important

safety issue for sport activities performed in minor leagues,

where the sport trainer/coach is generally the only reference for

athletes. The institution of mandatory and official courses in

CRP inside university teaching programs is highly auspicial, in

order to guarantee a wide distribution of sport trainers and assi-

stants able to face many medical emergencies. Considering the

need to have a formal certification to operate an AED in Italy, a

more effective cooperation with regional EMS and Scientific

Societies such as National Resuscitation Council seems urgent.

Most sport-related, sudden cardiac deaths occur in public sports

areas (track, gymnasium), where others athletes or insiders are

present: unfortunately only a reduced percentage of these wit-

nesses are potentially life-saving cardiopulmonary resuscitation

operators. The role of the bystanders in initiating resuscitation

should be valorized, starting from the bystanders par excellence

in sport facilities: coaches, trainers and assistant athletic train-

ers. Project focused on CPR training and placement of auto-

mated external defibrillators are thought to be both efficacious

and cost-effective, and for this reason a standardized, uniform

and ubiquitous teaching program should be provided to sport

students (Berger et al., 2004; Salib et al., 2005). Unfortunately

only a reduced number of Italian Universities with Bachelor

and Master-Level Degrees in sport and exercise sciences offers

dedicated courses for BLS-D with final national authorization/

license.

Acknowledgements

This work has been supported by the scientific collaboration

with the IRC Italian Resuscitation Council and the scientific

committee of ICSPS2013 (www.icsps-rome2013.it). Authors

thanks Dr. Elena Scaramucci (Sant’Andrea Hospital, Rome, Ita-

ly) for the collaborative discussion useful comments and critici-

sm.

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