A Novel Scoring System and Correlative Analysis of the Strength and Effectiveness of Nationwide High School Cardiopulmonary Resuscitation Mandates: Insights from a High School CPR Study

Abstract

Numerous states have introduced cardiopulmonary resuscitation (CPR) training mandates for high school students and staff to prevent sudden cardiac death (SCD). However, the content and implementation of these mandates vary substantially. Furthermore, a comprehensive and objective assessment of these mandates and their impact is lacking. To conduct a thorough evaluation of CPR training mandates across the United States. We developed a novel scoring system based on proposed CPR standards, training and certification requirements, and legislative action to assess current mandates. This was used to rate the CPR mandates across all 50 states and the District of Columbia. Mandate scores were then compared to available real-world registry data as a surrogate for efficacy from 2018 to 2021. State CPR mandate scores ranged from 0 to 47, with a higher score indicating more robust mandates. The median and mean scores were 24 [IQR 19.5-27] and 21.52±8.61, respectively, with 35 being the highest score. Intra-observer variability was 0.986 (95% CI 0.944-1.028; p<0.001). The year of implementation did not influence the strength of the score (R2=-0.173; 95% CI -0.447-0.131, p=0.262), Correlation between SCD rate (R2=-0.76; 95% CI -0.492-0.367, p=0.742), bystander-initiated CPR (R2= -0.006; 95% CI -0.437-0.427, p=0.978), automatic external defibrillator use (R2= -0.125; 95% CI -0.528-0.324, p=0.590), or cardiovascular death rate (R2=-0.13; 95% CI -0.379-0.21, p=0.355) failed to reach statistical significance. Modest scoring consistency highlights the need for robust, standardized CPR requirements to potentially mitigate SCD. This study lays the groundwork for evidence-informed policy development in this area.