Sudden cardiac arrest accounts for 15–20% of all deaths worldwide. ^{Reference Srinivasan and Schilling1} Several studies have demonstrated that prompt recognition of a cardiac arrest, early cardiopulmonary resuscitation, and defibrillation confers substantial survival benefit for out-of-hospital sudden cardiac arrest. Indeed, a 41–74% benefit has been reported when cardiopulmonary resuscitation training is administered within 3–5 min of collapse. ^{Reference Drezner, Rao, Heistand, Bloomingdale and Harmon2–Reference Swor, Grace, Mcgovern, Weiner and Walton7} A 7–10% decline in survival for every minute that defibrillation is delayed has prompted several health organisations to encourage the installation of automated external defibrillators in major public areas. ^{8–Reference Larsen, Eisenberg, Cummins and Hallstrom10} Most sporting organisations also mandate automated external defibrillators in sporting arenas. ^{Reference Borjesson, Serratosa and Carre11,Reference Malhotra, Dhutia and Gati12}

The sudden death of a young individual is a devastating tragedy for family and friends, stirring deep emotions and raises concerns about the vulnerability of other children and adolescents in society. Sudden cardiac death is a rare phenomenon, with 8–12 young healthy individuals passing away every week in the United Kingdom. ^{Reference Papadakis, Sharma, Cox, Sheppard, Panoulas and Behr13} Retrospective registries that record sudden cardiac death in young athletes and non-athletes estimate an incidence rate ranging between 0.1 and 6.8 deaths per 100,000 young individuals. ^{Reference Drezner, Rao, Heistand, Bloomingdale and Harmon2,Reference Papadakis, Sharma, Cox, Sheppard, Panoulas and Behr13–Reference Malhotra, Dhutia and Finocchiaro18} This is probably an underestimate as no mandatory reporting systems currently exist. The prevalence is regrettably hard to establish due to heterogeneity in study methodology and populations studied.

The effectiveness of early cardiopulmonary resuscitation training and defibrillation has also been demonstrated in young individuals. Several cases of successful resuscitation of students during athletic events and functions held at high schools and colleges have now been reported. ^{Reference Drezner, Rogers, Zimmer and Sennett3,Reference Drezner, Toresdahl, Rao, Huszti and Harmon19–Reference Coris, Miller and Sahebzamani21} Politicians and school administrators are increasingly recognising that this is an important public health concern. The availability of automated external defibrillators in schools is now on the rise in many countries including locally in Malta. Several countries have also created a legal framework to facilitate this process. Automated external defibrillators in most schools are now obligatory in one-third of United States of America states since February 2016. ^{Reference Sherrid, Aagaard and Serrato22} They are endorsed by the Department of Education in the United Kingdom. ²³ However, implementation is nation dependent. Most secondary schools in London do not have an automated external defibrillator readily available, ^{Reference Salciccioli, Marshall and Sykes24} whilst an Italian bill outlining the obligatory installation of automated external defibrillators in schools has been approved in 2021. ^{Reference Scapigliati, Semeraro and di Marco25} To date, the Ministry of Education in Malta has not yet endorsed nor provided any relevant recommendations to schools. There is also no legal framework to support the installation of automated external defibrillators in public places, hence this study.

All adolescents attending Year 5 secondary school classes in Malta (mean age 15 years) were invited to undergo cardiac screening that included a physician-led assessment together with ECG acquisition in schools. This BEAT-IT programme was a first of its kind, effectively screening 0.6% of the entire Maltese population. Nine (0.3%) students were given a diagnosis linked to sudden cardiac death, and another 27 (1.0%) are under surveillance because of symptoms and/or a pre-clinical pathological ECG findings. ^{Reference Abela, Xuereb and Camilleri26} These outcomes led to a local awareness campaign regarding cardiac arrest prevention and heart disease in young individuals. Early defibrillation and the chain of survival are heavily dependent on automated external defibrillator availability and good cardiopulmonary resuscitation training. Device location and the number of automated external defibrillators installed in schools are key players in this process. Cardiopulmonary resuscitation (CPR) training and recertification are also vital. The main objectives of this study were to evaluate these factors, primarily a) assessing CPR competence and certification amongst school staff, together with b) automated external defibrillator availability in all secondary schools in Malta and Gozo.

Results

Forty out of 54 schools (74.1%) completed the questionnaire. Most schools catered for mixed genders (57.5%). The majority were in the Northern Harbour district (37.5%). Two schools (5.0%) had a documented sudden cardiac arrest in one of their pupils in the past 10 years, one on school premises. The majority (n = 35, 87.5%) agreed that sudden cardiac arrest prevention is an important health concern (Table 1). Almost all schools favoured a systematic cardiac screening programme in schools (undecided n = 1, 2.6%; agree n = 9, 23.7%; strongly agree, n = 28, 73.7%).

Table 1. Introductory questions

The next section of the questionnaire addressed automated external defibrillator availability (Table 2). The majority have heard of an automated external defibrillator and its function (n = 39, 97.5%). Most schools are equipped with an automated external defibrillator (n = 37, 92.5%). Only one automated external defibrillator on site is typically present (n = 27, 75.0%). Most schools reported that their automated external defibrillator/s were in an easily accessible area (n = 35, 97.2%), defined in this study as “an area of no further than a 2-minute brisk walk from places in which they were likely to be used.” Despite this, almost half of the schools did not have a risk assessment prior to automated external defibrillator installation (n = 17, 47.2%). This consequently led to automated external defibrillators not being available on every floor in most (n = 37, 97.2%) and not being close to a sporting facility in almost one-third (n = 11, 30.6%).

Table 2. Automated external defibrillators in secondary schools

History of sudden cardiac arrest in a school pupil did not have any influence on the availability of automated external defibrillator (p = 0.860) or proximity to a sporting facility (p = 0.722). History of sudden cardiac arrest at school did not positively influence the number of installed automated external defibrillators (≤1 versus ≥ 2 automated external defibrillator, p = 0.413), but there seemed to be a direct relationship between history of sudden cardiac arrest at schools and automated external defibrillator availability on every floor (p = 0.056). More automated external defibrillators on school grounds did not influence the likelihood of device installation close to a sporting facility (p = 0.432). This was also independent of pupil gender (p = 0.691) and school location (p = 0.222).

Most schools do not organise regular cardiopulmonary resuscitation training courses (n = 21, 58.3%) (Table 3). The majority have staff certified in life support (n = 35, 89.7%). A quarter of schools report more than five certified staff members (n = 8, 23.5%), and the majority have undergone recertification (n = 28, 82.4%). The number of automated external defibrillators on site did not increase the likelihood of having cardiopulmonary resuscitation training courses organised at school (p = 0.607). Additionally, there was no association between the number of certified staff members and the number of installed automated external defibrillators (p = 0.806).

Table 3. Cardiopulmonary resuscitation competence and certification