Süss-Havemann et al.

BMC Public Health (2020) 20:50

https://doi.org/10.1186/s12889-020-8161-7

RESEARCH ARTICLE Open Access

Implementation of Basic Life Support

training in schools: a randomised
controlled trial evaluating self-regulated
learning as alternative training concept
Christoph Süss-Havemann1, Janina Kosan1, Thomas Seibold2, Nils Martin Dibbern3, Anne Daubmann4,
Jens Christian Kubitz1 and Stefanie Beck1*

Abstract
Background: The Kids save lives statement recommends annual Basic Life Support (BLS) training for school
children but the implementation is challenging. Trainings should be easy to realise and every BLS training should
be as effective as possible to prepare learners for lifesaving actions. Preparedness implies skills and positive beliefs
in the own capability (high self-efficacy).
Methods: This randomized controlled cluster study investigates, if self-regulated learning promotes self-efficacy and
long-term retention of practical BLS skills. Students in the age of 12 years participated in a practical training in BLS
and a scenario testing of skills. In the control group the practical training was instructor-led. In the intervention
group the students self-regulated their learning processes and feedback was provided by the peer-group. The
primary outcome self-efficacy for helping in cardiac arrest after the training and 9 months later was analysed using
a multilevel mixed model. Means and pass-rates for BLS skills were secondary outcomes.
Results: Contrary to the assumptions, this study could not measure a higher self-efficacy for helping in cardiac
arrest of the students participating in the intervention (n = 307 students) compared to the control group (n = 293
students) after training and at the follow-up (mean difference: 0.11 points, 95% CI: − 0.26 to 0.04, P = 0.135). The
odds to pass all items of the BLS exam was not significantly different between the groups (OR 1.11, 95% CI: 0.81 to
1.52, p = 0.533). Self-regulated learning was associated with a higher performance of male students in the BLS exam
(mean score: 7.35) compared to females of the intervention (female: 7.05) and compared to males of the control
(7.06).
Conclusion: This study could not resolve the question, if self-regulated learning in peer-groups improves self-
efficacy for helping in cardiac arrest. Self-regulated learning is an effective alternative to instructor-led training in
BLS skills training and may be feasible to realise for lay-persons. For male students self-regulated learning seems to
be beneficial to support long-term retention of skills.
Trial registration: ISRCTN17334920, retrospectively registered 07.03.2019.
Keywords: Basic life support training, Self-regulated learning, Self-efficacy, School children

* Correspondence: st.beck@uke.de
1
Department of Anaesthesiology, University Medical Center
Hamburg-Eppendorf, Martini-Str. 52, 20246 Hamburg, Germany
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 2 of 9

Background task but as well for the retention of skills [17]. The litera-
Ischemic heart disease is one of the leading causes of death ture discriminates between the learning processes relevant
in the world. According to international consensus, the for skill acquisition and retention. Immediate feedback of
most important determinant to survive a sudden cardiac a teacher improves in many contexts learning tempo and
arrest is the presence of a trained rescuer who is ready, higher initial performance. Self-regulation processes like
willing, and able to act [1, 2]. The Introduction of CPR setting learning goals, monitoring the own performance
training for school children is an effective intervention to and adapting strategies to achieve these learning goals is
improve bystander-CPR-rates and increased survival of positively associated with skill retention [18, 19]. There-
out-of-hospital cardiac arrest two- to four-fold [3]. fore this study hypothesised that self-regulated practical
Based on the existing evidence the joint-statement learning will increase the SE of school children for helping
“Kids save lives” was released. The statement aims to in cardiac arrest immediately after the training and until
introduce annual CPR training in the curriculum for all follow up 9 months later and will have a positive effect on
school children world-wide and was endorsed by the the retention of practical BLS skills.
World Health Organization in January 2015 [4].
Teachers, physicians, nurses, students and emergency Methods
medical staff engage in the training of school children, but A randomized, rater blinded, controlled cluster study
the implementation is difficult. The evaluation of nationwide was performed to evaluate the effect of two different
programs demonstrate that not all students were reached training methods. The trial was conducted in September
and some have been trained only once in their schooldays 2016 and the follow up was performed 9 months later in
[5–8]. Important barriers of implementation in schools are June 2017.
lack of instructors and equipment and assumed high costs
[7]. In turn there are some factors associated with good im- Participants
plementation rates. These factors are awareness of mandat- The participating schools were recruited from the pool
ing legislation and successful implementation at other of cooperating high-schools of the Department of An-
schools. As well as a person in charge for the implementation aesthesiology of the University Hospital Hamburg-
and teachers, who feel competent to conduct trainings [5]. Eppendorf. The students of grades seven and eight were
There is a need for training concepts, which are very randomised class-wise into the intervention- and control
effective and focus on the factors strongly associated arm in a 1:1 allocation ratio. The randomisation was
with patient outcome on the one hand and simple and performed in advance by drawing balls of two colours
easy to realise at the other hand. blindly. A cluster was represented by students of one
Training should focus on skills, because effective CPR is class. All students and their legal guardians were in-
crucial for survival. But skills are not the only constitutional formed in advance about the training and the study goal.
factor of CPR by bystanders [1]. The potential rescuer Only assessments of students who had their written in-
needs enough confidence e.g. perceived ability to perform formed consent to participate on hand were included in
effective CPR as well. Training improves the belief of the analyses.
potential-rescuers that they can perform CPR effectively.
But even trained people only perform CPR in 30–55% of Instruments
the given occasions [9, 10]. The main reasons for denying Practical skills were evaluated during a 3 min scenario
live saving cardiopulmonary resuscitation to a patient are testing using a nine point standardised checklist. The
fear and lack of confidence of potential-rescuers [11–13]. assessment has been developed for school settings and
To overcome fear and lack of confidence training high inter-rater reliability has been shown in a previous
methods should focus on positive beliefs and capabilities study [20]. Demographic data and the self-efficacy were
to master prospective situations. For conceptual design assessed before the practical assessment using a ques-
and measurement of effective teaching, self-efficacy (SE - tionnaire. The self-efficacy (SE) was measured with a
a person’s belief in his/her capability to organise and four-point Likert scale in three dimensions with two
execute the course of action required to produce given questions for each by adding the values of the two ques-
attainments [14] based on the concept Bandura) is a tions. The dimensions were helping in general, helping
promising target. Schrunk demonstrated that children in cardiac arrest and diminished emotional arousal to
derive more SE by observing others, who are similar to cardiac arrest. The questionnaire, based on the general
themselves (peers) succeeding at a task in contrast to ob- self-efficacy scale of Schwarzer and Jerusalem [21] was
serving adults and showed that training concepts which transformed into a special self-efficacy scale following
foster self-regulation processes improve SE [15, 16]. the authors recommendations (Table 1). The question-
Self-regulation processes during learning are not only naire was piloted and demonstrated higher SE of
helpful to stimulate the perceived ability to perform a students, who were promoted to be a BLS instructor
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 3 of 9

Table 1 Items of the self-efficacy questionnaire The assessment of the practical BLS skills during part
Domain: helping in general three was structured as an OSCE using MiniAnne-
1. I can help other people if I try hard. mannequins® (LaerdalTM). The medical students/ high
2. When I want to help other people, I am certain that I can accomplish
schools students were randomly assigned to an assess-
my goals. ment station. The students themselves were randomly
Domain: helping in cardiac arrest assigned to the assessment stations before entering the
gym. For assessment, the raters used a structured rating
3. In a cardiac arrest situation I am confident that I could deal efficiently.
checklist with nine binary items. To pass the practical
4. I can handle the situation if cardiac arrest comes my way.
assessment in total, all nine points had to be rated with
Domain: diminished emotional arousal to cardiac arrest yes. All raters were trained in advance to use the struc-
5. Thanks to my resourcefulness, I can handle unforeseen situations in a tured rating-checklist.
resuscitation-situation. At the initial assessment directly after the training the
6. I can remain calm when facing a cardiac arrest situation because I can probability of a rater knowing about the group affiliation
rely on my coping abilities.
differed from 1:6 to 1:2. The follow-up assessment was
Response format: 1 = Not at all true 2 = Hardly true 3 = Moderately true identical. But medical students evaluated the students
4 = Exactly true
and were totally blinded of group affiliation.
All trainers were invited to a seminar prior to the training
compared to students just participating in a BLS training in schools which included five parts [23]. The trainers were
[22]. Demographic data included age, gender, weight, randomised between part four and five to intervention or
height and previous CPR training. control group trainers. The randomization was performed
by letting the trainers choose a specific class without know-
Procedure ing if the class was randomised to the intervention or
Training and initial assessment of the students were part control group. In the fourth part the two groups were sepa-
of a CPR training event at the participating schools. The rated, informed about their training concept and practiced
CPR training event covered three school lessons (45 min it in a simulated BLS teaching session.
each) and consisted of three parts. Part one was a 45
min interactive lecture on basic life support and AED Data analysis
use. Part two was 45 min of practical training on BLS The primary outcome was the self-efficacy for helping in
and AED skills performed in small groups (16–24 stu- cardiac arrest immediately after the training and at the
dents with two trainers). Part three was the assessment. follow-up 9 months later. Secondary outcomes were
The practical training during part two was different be- pass-rates and means for BLS performance immediately
tween the intervention and control group. In both groups, and 9 months later.
the practical training was performed by trained medical
students or high school students (both in their final year Sample size calculation
before graduating) in the class rooms of the students and Sample size calculation was based on an estimated dif-
based on the four step-approach established by Peyton. ference between the self-efficacy for helping in cardiac
The four steps include 1. demonstration, 2. deconstruc- arrest of 0.25 points (SD ± 1) between the intervention
tion, 3. comprehension and 4. execution of the learned. In and control. We assumed, that the SE is higher in the
the control group the skills were trained following the four intervention group. With an α of 0.05 (two-sided) and a
step-approach. In the intervention the trainers performed power of 0.8, fifteen classes with 22 students per group
step one and two (demonstration and deconstruction). had to be analysed assuming an intracluster correlation
During step three and four the students guided their of 0.01. We decided to include as many classes as
learning self-regulated and the trainer supervised and sup- possible.
ported the communication process. The students were
split into small groups of 8 to 12 students and in turns the Statistics
children took over the part of the instructor, the executor The rating sheets were machine readable, electronically
or the rater of BLS. One student explained how and what scanned and imported into Microsoft Excel. After check-
to do next, two students performed BLS and the ing for plausibility, the data was analysed together with a
other students evaluated the performance and gave statistician of the Department of Medical Biometry and
feedback afterwards. To support the evaluating and Epidemiology of the Medical University of Hamburg
feedback-process the children used training cards with using SPSS, version 24 (IBM Corp, Armonk, NY, USA).
all relevant BLS items. The trainers stimulated the Descriptive statistics were evaluated for all randomized
children to guide their feedback based on the per- students by group. For the categorical variables, the
formance parameters on the training cards. absolute and relative frequencies were calculated. Means
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 4 of 9

and standard deviation (SD) were determined for con- group students and 237 of the control group students
tinuous variables. participated at the follow up nine months later (Fig. 1).
Assuming a dependence of SE on gender and the Demographic data were comparable between the groups
intervention and a dependence of practical skills on time and presented in Table 2. The proportion of the variance,
and the intervention, we considered gender and its inter- attributable to the students, was higher than the proportion
actions with group and time additionally in our model. of the variance attributable to the classes for all continuous
Therefore primary and secondary continuous outcomes outcomes (Table 3).
were analysed using a multilevel mixed model with For the main outcome of self-efficacy for helping in
group, gender and time as fixed effects, class as random cardiac arrests no significant difference between the
effect and time as a repeated effect. In the initial model groups (mean difference for helping in cardiac arrest:
the three-way- and all two-way-interactions between the 0.11 points, 95% CI: − 0.26 to 0.04, P = 0.135) was found.
three variables were included. Afterwards a stepwise Mean scores of male students of the control were de-
backward elimination of the not significant interactions scriptively higher compared to male students of the
was conducted. For the binary outcome (passing OSCE), intervention and female students of both groups
a mixed logistic regression was evaluated with the same (Table 4). SE for helping in cardiac arrest decreased sig-
specifications as in the model for continuous outcomes. nificantly over time (mean difference: 1.08 points, 95%
Mean differences and odds ratios with the corresponding CI: 0.97 to 1.20, p < 0.001).
95% confidence intervals (CI) were reported, respect- For helping in general and diminished emotional
ively. Intra-Cluster-Correlations (ICC) were also pre- arousal to cardiac arrest the control group had signifi-
sented. Two-sided p-values < 0.05 were considered as cant higher means (mean difference for helping in gen-
significant. eral: 0.18 points, 95% CI: 0.01 to 0.35, P = 0.038), mean
difference for diminished emotional arousal: 0.20 points,
Results 95% CI: 0.01 to 0.39, P = 0.045).
847 students were randomized and trained. 247 did not A significant decrease over time was observed P <
have written informed consent and the data of these 0.001 (helping in general: 0.54 points, 95% CI: 0.44 to
students was not included in the analyses. Data of 307 0.65; diminished emotional arousal: 0.96 points, 95% CI:
students of the intervention group (20 Clusters) and 293 0.82 to 1.09).
students of the control group (21 Clusters) could be ana- Observed means separated for group, gender and time
lysed immediately after the training. 257 of the intervention are presented in Table 4.

Fig. 1 Flow-chart of participants according to CONSORT recommendation

Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 5 of 9

Table 2 Demographic data of the students assessing breathing, compression frequency, compres-
Intervention (n = 307) Control (n = 293) sion depth and pauses less than 30 s compared to male
Age–yr (S.D.) 12 (1) 12 (1) students after control at the follow-up. Male students of
Male gender – no. (%) 139 (45.3) 147 (50.2)
the intervention performed chest compression after nine
months nearly as good as immediately after training.
Height–cm (S.D.) 160 (7.8) 161 (8.6)
After nine months all groups passed about 0.6 to 0.7
Weight– kg (S.D.) 46.5 (8.0) 47.6 (9.4) items less; except the males in the control group de-
CPR-training < 1 year – no. (%) 4 (1.4) 5 (1.7) clined about 1.1 items.
CPR-training > 1 year – no. (%) 16 (5.2) 13 (4.4) Independent of the group, the pass rates for checking
No CPR-training ever – no. (%) 284 (92.5) 274 (93.5) breathing declined strongly approximately 20% over
time. The decline of pass-rates for the other items
ranged within 10%.
A mean pass-rate of 25% of all students without a
significant difference between the groups was detected Discussion
(OR 1.11, 95% CI: 0.81 to 1.52, p = 0.533). The odds to This study demonstrates that a high percentage of students
pass the exam declined significantly over time without had self-confidence to help effectively in cardiac arrest after
any interaction between groups. The chance to pass the the training and nine months later. Practical skills of the
exam was 2.64-fold higher directly after the training than students were high after both training concepts and male
nine months later. (OR 2.64, 95% CI: 1.88 to 3.69, P < students seem to benefit from self-regulated training. Be-
0.001). Gender had no significant influence on the odds cause the instructors used moderation skills but disclaimed
to pass. feedback based on their clinical skills in the self-regulated
For number of passed items in BLS, the interaction training, even lay people may realise self-regulated learning
between group and gender was not significant with p- when using videos for the initial demonstration and decon-
value of 0.052. The significance was just missed. In this struction of BLS skills.
case, nevertheless, we kept the interaction in the model. Based on the literature we had expected a positive effect
Male students of the intervention had passed more items of self-regulated learning on the SE for helping in cardiac
than the female in the intervention (male: 7.35, 95% CI: arrest, because the intervention is grounded on the theor-
7.11 to 7.58, female: 7.05, 95% CI: 6.82 to 7.27, differ- etical concept to support SE developed of Bandura and
ence: 0.30, 95% CI: 0.06 to 0.55, P = 0.015). In the con- included recommended instructional strategies to boost
trol group, no significant difference between male and SE in the context of medical learning [24]. Evidence based
female students was found. For female and male stu- strategies as “setting of challenging and proximal goals”,
dents, the scores did not differ significantly between the “providing honest and explicit feedback”, “use of peer
groups (female: intervention: 7.05, 95% CI: 6.82 to 7.27; modelling” and “facilitation of accurate calibration of SE”
control: 7.10, 95% CI: 6.86 to 7.33, difference: -0.05, 95% were part of the self-regulated concept but did not
CI: − 0.37 to 0.26, P = 0.746; male: intervention: 7.35, improve SE for helping in cardiac arrest. Additionally, a
95% CI: 7.11 to 7.58; control: 7.06, 95% CI: 6.83 to 7.29, significantly lower SE for helping in general was measured
difference: 0.29, 95% CI: 0.03 to 0.61, P = 0.073). Time in the intervention compared to the control-group, which
had a significant influence on number of passed items served as a control variable, and there were also lower
(mean difference: 0.76, 95% CI: 0.60 to 0.92, P < 0.001). scores for diminished emotional arousal.
Observed means separated for group, gender and time In our opinion, a possible explanation is the so called
are presented in Table 4. “calibration effect”. Immediate feedback that encourages
Descriptive analyses (Fig. 2) showed that male students students to shift their focus from actual performance to
of the intervention had higher pass-rates for correct performance monitoring and evaluation is a strong pro-
compression frequency and depth after the training and motor of self-efficacy calibration and learning [25, 26].
at the follow-up compared to females of the interven- The featured role of peer feedback in the intervention
tion. Males of the intervention had better results for could have resulted in good self-efficacy calibration and

Table 3 Intra-Cluster-Correlations (ICC) for continuous outcomes

Outcome ICC of the classes ICC of the students
SE helping in general (% of total variance) 3.38 20.98
SE helping in cardiac arrest (% of total variance) 0.64 17.03
SE diminished emotional arousal (% of total variance) 2.09 15.82
Number of passed items in BLS (% of total variance) 6.38 7.33
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 6 of 9

Table 4 Means of self-efficacy and means of passed items of the BLS exam
Intervention Control
after training follow-up after training follow-up
SE helping in general (mean; SD) all 6.88 (1.03) 6.37 (0.95) 7.03 (0.96) 6.47 (1.04)
male 6.81 (1.08) 6.29 (0.99) 7.01 (0.95) 6.48 (1.07)
female 6.93 (1.00) 6.44 (0.90) 7.06 (0.97) 6.45 (1.01)
SE helping in cardiac arrest (mean; SD) all 7.09 (1.02) 6.02 (1.10) 7.20 (0.90) 6.13 (1.21)
male 7.10 (1.08) 6.02 (1.24) 7.38 (0.85) 6.19 (1.32)
female 7.09 (0.97) 6.02 (0 .98) 7.03 (0.92) 6.07 (1.07)
SE diminished emotional arousal (mean; SD) all 6.05 (1.17) 5.09 (1.33) 6.23 (1.13) 5.27 (1.23)
male 6.05 (1.20) 5.11 (1.39) 6.30 (1.22) 5.29 (1.25)
female 6.04 (1.15) 5.08 (1.28) 6.16 (1.03) 5.25 (1.22)
Number of passed items in BLS (mean; SD)
male 7.66 (1.21) 7.05 (1.54) 7.37 (1.43) 6.72 (1.49)
female 7.61 (1.13) 6.49 (1.58) 7.41 (1.45) 6.77 (1.48)

Fig. 2 Pass-rates for the BLS-exam and on item level. In the panels at the top the results of the male and at the bottom the results of the female
participants are presented. Panels on the left show results immediately after training and on the right nine months later
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 7 of 9

reduction of common overestimation of SE in the male of students including a mid-time follow-up after two differ-
group [27, 28]. This thesis is supported by the fact, that ent training methods. This study focused on the efficacy of
the males of the control had the highest SE scores but training methods in a real world setting with trained med-
the lowest scores for BLS at the follow up. The literature ical students or high school students as facilitors and stu-
reports some evidence, that female students possess and dents of grades seven and eight as learners. The objectivity
use more self-regulated learning strategies at this age and reliability of the of the SE- and practical skills assess-
than males [28]. Therefore, a teaching method that pro- ment can be estimated high because standardised assess-
motes self-regulation may be less effective for females at ment instruments were used, the assessors were blinded for
this age. group allocation. The variance within the results for the SE
The results support the thesis, that self-regulated learn- and number of passed items is mainly attributable to differ-
ing leads to good calibration of SE especially in male ence between the students and not between the classes.
students but the study missed to measure the accuracy of The low variance on class level indicates high reliability of
SE judgment of the students. Cleary [29] summarized the instrument and a slight influence of the trainer on the
methods that allow measuring over- or underestimation results. The sample size was high enough to detect a signifi-
of SE. For our setting it would be feasible to let the stu- cant interaction between training method and gender on
dents estimate if they can perform certain items correctly the mid-term BLS performance.
or to guess the grade they would achieve in the practical
assessment and compare it with the actual performance. Limitations
Additionally, we recommend using questionnaires to But the study was powered to evaluate the effectiveness of
evaluate SE for helping in cardiac arrest with more dis- self-regulated learning on the SE to help in cardiac arrest.
crimination power at the upper end for further studies. We expected higher SE of the students after self-regulated
In this study the pass-rates of about 25% in the BLS learning. There are two explanations for failing to measure
assessment appear low. There are two possible reasons. a difference. First, all groups scores above 7 (of an eight-
The students were very young and the assessment was point scale) initially and above 6 at the follow-up were ob-
very restrictive. served for helping in cardiac arrest. The discriminating
Students with a mean age of 14 years and a mean weight power between the single subjects and groups was limited
of 55 kg, who had participated in 2013/14 in our BLS- due to a ceiling effect of the used SE scale.
training with the same training setting and assessment, Second, we probably observed better calibration of the SE
had achieved pass-rates of about 40% [30]. Compared to in the male group after the intervention. To assess the ac-
the students with 14 years, the 12-year-old students of this curacy of SE calibration additional measures must be added
study had about 20% lower pass-rates for the items com- in future studies on self-efficacy. According to the literature
pression depth, compression rate and pauses less than 30 good SE calibration is a strong predictor for future success-
s. This is in line with the literature demonstrating higher ful performance and effective chest compression is essential
physical capacity to maintain effective chest compression in resuscitation. The effect of the intervention on behaviour
with higher age and higher weight [31]. in a real-world situation can’t be tested.
With respect to retention of practical skills, self-regulated The results depend on how self-regulated learning was
learning is only beneficial for male students. The difference realised in this study. If the self-regulated learning con-
between the males and females in the intervention is mainly cept brings more teachers to become facilitators of BLS
attributable to long-term retention of practical skills of training and helps to support the implementation, can’t
chest compression. The males of the intervention scored be predicted. The teachers do not need formal training
higher than the males of the control because of better in BLS to provide self-regulated learning opportunities
retention for breathing check, chest compression quality but must be familiar with the training material and mo-
and less pauses. Up to date there are only some studies tivated to create opportunities.
reporting an interaction between gender and training
method in medical education, because gender is not rou- Conclusions
tinely considered as variable in the analysis [31]. Sopka This study could not demonstrate that self-regulated
et al. demonstrated that the training environment interacts learning supports higher self-efficacy for helping in
with learning of different genders. Female medical students cardiac arrest in students. Self-regulated learning is an
improved CPR skills only in the female only group and not effective alternative to instructor-led training in BLS and
in mixed-gender groups [32]. may be feasible to realise for lay-persons like teachers.
For male students self-regulated learning seems to be
Strengths beneficial to support learning and long-term retention
The study was a randomised controlled trial with a sce- of skills. For female students the method of training
nario testing of practical skills and an assessment of SE seems less important.
Süss-Havemann et al. BMC Public Health (2020) 20:50 Page 8 of 9

Abbreviations Resuscitation and Emergency Cardiovascular Care Science With Treatment

AED: Automated External Defibrillator; BLS: Basic Life Support; Recommendations. Resuscitation. 2010;81:e1–e25.
CPR: Cardiopulmonary resuscitation; OSCE: Objective Structured Clinical 2. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-
Examination; SE: Self-efficacy of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation.
Circ Cardiovasc Qual Outcomes. 2010;3:63–81.
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support from the participating schools. Sincere thanks is given to the Vice survival after out-of-hospital cardiac arrest. JAMA. 2015;310:1377–84.
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responsible for the acquisition of data. CSH, AD and SB performed the 8 years of mandating legislation in Denmark: a nationwide survey. J Am
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with equipment (CPR mannequins). The Ministry of education had no role in professionals hesitate to perform. Resuscitation. 2014;85:e181–2.
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