Bystander CPR is a major factor for survival from out-of-hospital-cardiac-arrest (OHCA). This survey was performed to determine the current attitudes and fears, so as to allow targeted education to address the need to improve bystander CPR rates significantly in the near future. To the authors’ knowledge, this was the largest survey done to date in Singapore investigating fears and confidence levels regarding CPR, and willingness to attend further training.
Overall, the skills taught during CPR training were felt to be manageable and not difficult. Difficulty was less amongst those with previous CPR training. This supports the need for refresher courses to maintain CPR skills. A large proportion of participants also indicated interest in refresher training. This was also echoed in a 2017 UK survey (3) which showed previous training, especially in the previous five years, being the most important factor in determining willingness to perform CPR.
Amongst specific skills, recognition of a non-responsive patient was rated to be the easiest. While the use of training manikins might not translate well to a real-world scenario with humans, instructors at this mass event used participant’s training partners as subjects to teach recognition of breathing. This allowed a greater sense of realism for recognition of the factors associated with life, absence of which would be considered as criteria to begin CPR.
The most difficult skills rated were MMB and CC. This was similarly noted in a Norwegian study(4). MMB was more difficult in the oldest age group. CC was also more challenging in the extremes of age, likely owing to muscle mass and health related reasons. CPR training should focus on these practical aspects and maximise the hands-on time to increase confidence in the skills, especially when addressing age groups of concern.
A minority of participants did not see value in repeating the course, already having learnt the skills once. Notably, most of these had no previous CPR training, and might not yet be aware of the benefits of refresher training(5)(6). Repeated and effective CPR training will increase the learner’s willingness and confidence to perform CPR when needed. In addition, CPR training should address the occurrence of skills attrition and need for refresher training.
A large proportion of participants would recommend their entire family and all members of public to be CPR-trained. An anomaly however was that only 10% wanted their bosses to be trained in CPR and 20% for their colleagues. A possible reason is the large young non-working group of participants who may not yet appreciate the value of having many trained work colleagues with the skill.
70% all OHCA cases occur in residential areas(7), and have lower bystander CPR rates (13.6% vs 38.9%) and poorer survival outcomes – 0.9% vs 2.7% rate of survival to discharge, as compared to OHCA in non-residential areas(8). With the advent of dispatcher-assisted CPR (DACPR), the likely higher rate of bystander CPR in residential OHCA can result in more survivors. Most participants would perform 30:2 CPR for their family members and members of the public. With CPR training more widely carried out, bystander CPR in residential areas can be improved to in excess of 60%. A combination of DACPR, early activation of the emergency ambulance services and self-administered 30:2 CPR will be most likely to lead to improved survival outcomes. Every minute delay in CPR in a patient with cardiac arrest leads to a further reduction in survival(9).
Most participants would perform 30:2 CPR and only 20% would choose to perform CC only. In view of this promising attitude, CPR training for the public should continue to include 30:2 CPR with MMB to optimise conditions for survival. There are multiple conditions in which 30:2 CPR may have better outcomes than CC only, such as drowning, trauma, asphyxia(10), and in paediatric cases(11). A meta-analysis in 2010 showed dispatcher-assisted CC only to be associated with improved survival compared to dispatcher-assisted 30:2 CPR(12). This does not mean that non dispatcher-assisted CC in better than bystander 30:2 CPR. There is still a need to continue standard 30:2 CPR for training of the public to optimize survival rates and reduce risk of hypoxia-induced encephalopathy.
The most significant fear expressed was a low level of confidence. This is echoed across many other countries, including Norway(4), Hong Kong(13), Wales(14), Scotland(15). Interestingly, the fear of causing injury was only 9%, in contrast to that reported at 22% in Scotland, 28% in Hong Kong and 22% in Wales. The fear of acquiring infection was only 8.2%, again similar to that reported in Hong Kong at 6.2% and Scotland at 10%. This together with the low reported aversions to doing MMB again supports the need to continue with conventional CPR training for public(16). We note that the bulk of aversion to MMB in bystander CPR performance comes from health-care workers(17–22).
In terms of legal repercussions, although there is no Good Samaritan law in Singapore, only 2.5% of participants were fearful of this. Conversely in China(23), Hong Kong and Taiwan(24), the fear of legal action was considerably higher from 14.3–53% owing to the perceived lack of a Good Samaritan Law. However, 50 participants suggested to have Good Samaritan Laws available to help the rescuer.
These identified fears can be used to enhance focus on education to reduce these barriers. To combat the low level of confidence, taking into account the higher difficulty reported earlier for the practical skills of MMB and CC, courses can consider increasing time for practical skills. To increase rates of bystander CPR in the community, the suggestions given included public awareness activities, having free and easily accessible CPR courses for the public and implementing CPR training in all schools.