With an unwavering dedication to her profession, PSI’s Suzanne Evans, RN, BSN, LSN, NCSN consistently explores avenues to elevate her school’s readiness for unexpected emergencies. Having served as a local school nurse for 14 years and 23 years of experience as a registered nurse (RN), Suzanne found inspiration to write this article after successfully implementing a Cardiac Emergency Response Plan. It was during the past year that she conducted her inaugural drill, receiving overwhelmingly positive feedback from both her district and the community. The core objective behind her initiative was to formulate a protocol designed to equip educators, staff, and healthcare providers with the necessary knowledge and skills to respond promptly and efficiently to cardiac emergencies within a school environment.

Suzanne’s article was published in a recent edition of the National Association of School Nurses Online (NASN) and she is scheduled to conduct a breakout session on the Cardiac Emergency Response Plan at the NASN National Conference in June 2024, sharing her expertise and experiences with fellow school nurses from across the nation. Way to go Suzanne!

Cardiac Emergency Response Plan: Is Your School Prepared?

By Suzanne Evans, RN, BSN, LSN, NCSN and Maureen Legg

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School nurses play a major role in school readiness and emergency management, collaborating in safety assessment of schools and leading efforts to ensure the overall wellness of each child. Sudden cardiac arrest is a growing concern among students, and schools are a place of gathering, not only of our students and educators but also for the community, as family and friends support children in performances, sporting events, and religious or cultural activities. Implementing a school Cardiac Emergency Response Plan (CERP) provides a lifesaving resource for the entire community. This article will review the incidence of sudden cardiac arrest, discuss the latest guidance regarding preventive cardiac screening questions for all children, and share how one school district implemented a CERP using readily available resources.

Sudden Cardiac Arrest

Football fans across the nation sat in silence on January 3, 2023, watching as 24-year-old Buffalo Bills defensive player Damar Hamlin collapsed 9 minutes into the game. Damar suffered sudden cardiac arrest (SCA) due to commotio cordis, which is caused by a blunt blow to the chest during a precise moment of the cardiac cycle (Merschel, 2023). Due to the quick response of a robust team of athletic and medical personnel on the field that day, Damar was revived and has celebrated a full recovery. Fortunately, and incredibly, this outcome was repeated in July 2023, when rising basketball player Bronny James collapsed with SCA during a practice at the University of Southern California, where ample support was provided in advance of Emergency Medical Services (EMS) arriving and contributed to his survival (American Heart Association [AHA], 2023). Naturally, public and private K–12 schools do not have the level of available athletic resources as do the National Football League or Division I Universities, yet every youth deserves the same chance for survival.

Recent estimates report more than 356,000 individuals having an out-of-hospital cardiac arrest in the United States every year (Benjamin et al., 2018). Although U.S. data specific to children and youth are lacking, estimates range from 7,000 to 23,000 deaths each year due to an SCA event (Okubo et al., 2020; Parent Heart Watch, 2023), and SCA is reported to be the leading medical cause of death in student athletes (Harmon et al., 2015). The American College of Cardiology published a study of SCA in U.S. high schools and determined that two in 50 schools can expect an event each year (Sherrid et al., 2017). Recognizing the need for more accurate data in the United States on the incidence and cause of sudden death in young people, the National Institutes of Health (NIH, 2013) and the Centers for Disease Control and Prevention (CDC) launched a registry (Sudden Death in the Young Case Registry: https://sdyregistry.org/). Beginning in 2014, state public health agencies were encouraged to apply to participate in the registry, with the CDC initially accepting up to 15 states or major metropolitan areas. For more information about this registry and to find participating states and areas, see https://www.cdc.gov/sids/case-registry.htm. The registry tracks sudden death in the young in addition to sudden unexpected infant death.

Prevention of SCA Deaths

Many SCA deaths can be prevented through early detection. In 2012 (Drezner et al., 2012), an American Board of Family Medicine study noted that 72% of students who suffered from SCA were reported by their parents to have at least one symptom before the event, though parents did not recognize the symptom(s) as life-threatening. Regular heart screening has been endorsed by the American Academy of Pediatrics (AAP) and is now part of its Bright Futures Periodicity Schedule for Preventive Pediatric Health Care (Erickson et al., 2021) specifying warning signs and family risk factors that should be addressed by the practitioner with diagnostic follow-up. It is suggested the primary care provider (PCP) use the four screening questions not just with student athletes, but with all children a minimum of every 3 years and upon entry into middle or junior high school and high school (see Image 1). Depending on the family’s and PCP’s concerns, more frequent screening is recommended. Advising parents of observed warning signs to review with their practitioner and connecting them as needed with school-based health care addresses a major public health consideration in SCA prevention. Yet, many SCA victims are not identified in advance of the event, even with screening and additional testing making preparedness for response a priority (Erickson et al., 2021).

Is My School Prepared to Respond to an SCA?

Having a Cardiac Emergency Response Plan (CERP) for your school is crucial to saving lives. Schools that create a CERP and conduct drills have a 70% chance of the event ending in survival (Travers et al., 2015) versus less than 10% for those without (Graham et al., 2015). In evaluating your school’s SCA emergency preparedness, several things can lead to a false sense of security. You may have several of your staff certified in cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED). You may have an AED accessible on your athletic fields and additional units strategically placed around your school. You may feel confident that you are prepared for a cardiac emergency on your campus. It is important to emphasize that having AED(s) accessible does not ensure the staff or coaches will know how to react in a cardiac emergency. However, a robust CERP engages all bystanders to take immediate action; no certification is necessary.

Data from the Cardiac Arrest Registry to Enhance Survival (CARES) report an average of just 40% of SCA victims in the United States receive bystander hands-only CPR and only 11% of victims who arrested in public had a bystander apply an AED (CARES, n.d.). It is clear we are not adequately empowering bystanders to engage. The majority of the public either forgot or were never trained in performing CPR and most feel more confident responding to a natural disaster, fire, or choking victim than they do in using an AED (Sudden Cardiac Arrest Foundation, 2019). It is important to make time to educate our youth. Studies show that 1) children as young as 6 and 7 years of age can be taught to seek help for SCA victims by calling 911. 2) Children as young as 9 years of age can recognize quality CPR chest compressions. 3) Youth aged 11 and 12 years can properly apply an AED within 90 seconds after receiving verbal instructions (Fuchs et al., 2018).