Resuscitation 84 (2013) 1574–1578

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Simulation and education

Current knowledge of and willingness to perform Hands-OnlyTM CPR in

laypersons
Jennifer Urban, Henry Thode, Edward Stapleton, Adam J. Singer ∗
Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Recent simplified guidelines recommend Hands-OnlyTM CPR for laypersons and efforts to
Received 22 August 2012 educate the public of these changes have been made. We determined current knowledge of and willing-
Received in revised form 21 March 2013 ness to perform Hands-OnlyTM CPR.
Accepted 15 April 2013
Methods: Design—prospective anonymous survey. Setting—academic suburban emergency department.
Subjects—adult patients and visitors in a suburban ED. Survey instrument—33 item closed question for-
mat based on prior studies that included baseline demographics and knowledge and experience of CPR.
Keywords:
Main outcome—knowledge of and willingness to perform Hands-OnlyTM CPR. Data analysis—descriptive
Hands-only CPR
Knowledge
statistics. Univariate and multivariate analyses were performed to determine the association between
Training predictor variables and knowledge of and willingness to perform Hands-OnlyTM CPR.
Survey Results: We surveyed 532 subjects; mean age was 44 ± 16; 53.2% were female, 75.6% were white. 45.5%
were college graduates, and 44.4% had an annual income of greater than $50,000. 41.9% had received
prior CPR training; only 10.3% had performed CPR. Of all subjects 124 (23.3%) had knowledge of Hands-
OnlyTM CPR, yet 414 (77.8%) would be willing to perform Hands-OnlyTM CPR on a stranger. Age (P = 0.003)
and income (P = 0.014) predicted knowledge of Hands-OnlyTM CPR. A history of a cardiac related event
in the family (P = 0.003) and previous CPR training (P = 0.01) were associated with likelihood to perform
Hands-OnlyTM CPR.
Conclusions: Less than one fifth of surveyed laypersons knew of Hands-OnlyTM CPR yet three quarters
would be willing to perform Hands-OnlyTM CPR even on a stranger. Efforts to increase layperson education
are required to enhance CPR performance.
© 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction the new guidelines recommend changing the sequence to C–A–B in

which resuscitation begins with chest compressions. As a result, the
With approximately 350,000 people suffering a cardiac arrest Basic Life Support (BLS) algorithm has been simplified and Hands-
each year in the US and Canada, cardiac arrest remains a major pub- OnlyTM (compression only) CPR is encouraged for the untrained
lic health problem.1 Despite advances in prevention and treatment, lay rescuer.5 Hands-OnlyTM CPR is also easier to perform and can
mortality from cardiac arrest remains unacceptably high.2 Success- be readily guided over the telephone by dispatchers.6
ful resuscitation after cardiac arrest is dependent on early recogni- The quest to train lay rescuers in CPR has been ongoing since
tion, early and effective CPR, and rapid defibrillation, followed by the 1960s.7 Several studies have documented a two to three fold
advanced life support and integrated post-cardiac arrest care. increase in survival rates for sudden cardiac arrest when bystander
Based on the evidence,3 the American Heart Association pub- CPR is provided at the moment of collapse.8–10 Therefore, training a
lished new Guidelines for Cardiopulmonary Resuscitation (CPR) critical mass of lay rescuers remains a priority goal for the American
and Emergency Cardiovascular Care (ECC) in 2010 emphasizing the Heart Association and American Red Cross organizations.
importance of chest compressions and early defibrillation.4 With However, training a large number of rescuers through tradi-
the standard A–B–C sequence the lay responder opens the airway tional classroom programs remains a daunting task, due to logistics,
to give mouth-to-mouth breaths followed by chest compressions. instructor–student ratios, and costs associated with the program.
Since many responders may be reluctant to deliver mouth-to- Numerous strategies have been utilized to reach a large number of
mouth breaths and the A–B–C sequence delays chest compressions, lay people in a more efficient manor, including; mass training,11
video self-instruction,12 and use of the mass media as an educa-
tional tool,13 yet the rate of bystander CPR is still very low in many
communities.3 Additionally, both lay rescuers and professionals
∗ Corresponding author. Tel.: +1 631 444 7857. have demonstrated a lack of willingness to perform mouth-to-
E-mail address: [email protected] (A.J. Singer). mouth rescue breathing.14

0300-9572/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.resuscitation.2013.04.014
 J. Urban et al. / Resuscitation 84 (2013) 1574–1578 1575

The promotion of Hands-OnlyTM CPR represents an opportunity Table 1

Characteristics of study participants.
to train a large number of lay rescuers using much more simplistic
and efficient strategies that can be applied in a matter of min- Characteristic Frequency Percent
utes by using video or video plus a manikin.15 A broad national Gender
campaign has been underway since the release of the Hands- Male 242 45.5
OnlyTM recommendation by the American Heart Association.16 Female 283 53.2
Mass media coverage of the Hands-OnlyTM recommendation has No response 7 1.3
Total 532 100.0
been extensive in the United States. Stories have appeared in major Race
newspapers,17,18 television programs19 and a large campaign on White 402 75.6
the internet.20 A Google search for Hands-OnlyTM CPR generated Black 40 7.5
over 1.7 million hits. Hispanic 39 7.3
Asian/Pacific Islander 20 3.8
While there have been major efforts to educate the public on
Native American 4 0.8
Hands-OnlyTM CPR it is unclear how many laypersons are actually Other/multiple races 23 4.3
aware of the recent changes in CPR. A study of a mass information No response 4 0.8
campaign in South Korea demonstrated a significant increase in Total 532 100.0
public awareness of CPR in general.21 Language
English 490 92.1
However, in a recent study of Hands-Only CPR, there was a Spanish 18 3.5
significant increase in the number of people performing CPR; a Other language 23 4.3
larger percentage of rescuers performing Hands-Only CPR; and No response 1 0.2
an increase in out-of-hospital survival when Hands-Only CPR was Total 532 100.0
Highest level of education
utilized.22 The main goal of the current study was to determine cur-
<High school 7 1.3
rent knowledge of and willingness to perform Hands-OnlyTM CPR High school 199 37.4
among a sample of laypersons. College 242 45.5
Graduate school 80 15.0
No response 4 0.8
2. Methods Total 532 100.0
Marital status
2.1. Study design Single 169 31.8
Married 298 56.0
Divorced 43 8.1
We conducted a prospective anonymous survey to determine
Widowed 20 3.8
layperson knowledge of and willingness to perform Hands-OnlyTM No response 2 0.4
CPR. All patients gave verbal informed consent and the study was Total 532 100.0
approved by our Institutional Review Board. Income
<30K 101 19.0
30–50K 92 17.3
2.2. Setting and study subjects 50–100K 174 32.7
>100K 62 11.7
The study was conducted at an academic suburban emergency No response 103 19.4

department with an annual census of 90,000 and an affiliated

emergency medicine residency training program. Study subjects
education) and knowledge of and willingness to perform Hands-
included any adult (>18 years) patients or visitors presenting to
OnlyTM CPR. Predictor variables that had a univariate P-value of 0.2
our ED when one of the study investigators or research assistants
or less were included in a stepwise logistic regression.
were present who agreed to participate in the survey. Trained
research assistants are present in our ED from Monday through
3. Results
Friday between 10 am and 6 pm.

During the study period we enrolled 532 participants. Their

2.3. Survey instrument mean (SD) age was 44 (16) years. Of all subjects 283 (53.2%) were
female, 402 (75.6%) were white, 40 (7.5%) were African American,
We used a 33 item closed question format survey based on prior and 39 (7.3%) were Hispanic. The primary language was English
studies that included baseline demographics (e.g., age, gender, edu- in 490 (92.1%) subjects, and many participants (45.5%) reported
cation, income) and knowledge and experience of CPR. An example college as their highest level of education. Table 1 summarizes
of the survey can be accessed online. additional demographic information for the study subjects.
Out of the 532 study subjects surveyed, 223 (41.9%) had pre-
2.4. Outcomes viously taken a CPR course. About half of the participants reported
that they did not feel confident in their ability to perform CPR. Of all
The main outcome of the study was prior knowledge of Hands- subjects, 59 (11.1%) reported that they had personally suffered from
Only CPR. A secondary outcome was the willingness to perform a heart attack or other heart related problem while 58.6% of par-
Hands-Only CPR on a relative, acquaintance, or a stranger. ticipants reported that someone in their family has suffered from
a heart attack or heart-related problem. 66.5% of subjects surveyed
2.5. Data analysis reported that they would feel confident in recognizing if someone
was suffering from a heart attack while only 39.8% of people sur-
We used descriptive statistics to summarize the data. Contin- veyed said that they would expect to see different heart attack signs
uous data were summarized as means and standard deviations. in women as opposed to men. Only 55 (10.3%) of the subjects sur-
Binary and other categorical data were summarized as percentages veyed had performed CPR previously and only 97 (18.2%) of the
frequency of occurrence together with 95% confidence intervals participants reported that they would attempt CPR again.
(CI). Univariate and multivariate analyses were performed to deter- When asked what was the current recommended protocol for
mine the association between predictor variables (such as age and layperson CPR, only 124 (23.3%, 95% CI 19.9–27.1%) of participants
1576 J. Urban et al. / Resuscitation 84 (2013) 1574–1578

Table 2 Table 3
Univariate association between predictor variables and knowledge of Hands-OnlyTM Univariate association between predictor variables and willingness to perform
CPR. Hands-OnlyTM CPR on a stranger.

Predictor No. % of participants who P value Predictor No. % of participants who P value
knew about would perform
Hands-OnlyTM CPR Hands-OnlyTM CPR on
an unknown person
Age .01
18–39 217 18.0 Age .46
40–64 257 25.3 18–39 212 79.7
65+ 55 36.4 40–64 254 80.7
Gender .95 65+ 52 73.1
Female 283 23.3 Gender .91
Male 242 23.6 Female 277 79.8
Race .22 Male 237 80.2
Caucasian 402 25.1 Race .20
African American 40 17.5 Caucasian 395 80.5
Other/unspec. 90 17.8 African American 40 85.0
Education .14 Other/unspec. 85 72.9
<High school 7 0 Education .16
High school 199 19.6 <High school 6 66.7
College 242 26.9 High school 198 76.8
Graduate 80 25.0 College 236 83.9
Any previous CPR training .46 Graduate 77 75.3
Yes 223 24.7 Any previous CPR training .009
No 301 21.9 Yes 223 84.8
Prior heart attack .008 No 293 75.4
Yes 59 37.3 Prior heart attack .53
No 469 21.7 Yes 58 82.8
Family history heart attack .19 No 462 79.2
Yes 312 25.6 Family history heart attack .003
No 213 20.7 Yes 309 84.1
Health related career .86 No 208 73.6
Yes 23 21.7 Health related career .16
No/unspec. 509 23.4 Yes 23 91.3
Income .01 No/unspec. 497 79.1
<$30,000 101 22.8 Income .82
$30,000–$50,000 92 16.3 <$30,000 100 78.0
$50,000–$100,000 174 31.6 $30,000–$50,000 90 76.7
>$100,000 62 16.1 $50,000–$100,000 172 82.6
Unspecified 77 16.9 >$100,000 59 79.7
Unspecified 75 80.0

chose Hands-OnlyTM CPR followed by 25.0% of people choosing Table 4

breaths followed by compressions, 20.3% choosing compressions Multivariate association between predictor variables and knowledge of Hands-
followed by breaths, 2.4% choosing ventilation only CPR, and 28.9% OnlyTM CPR.
having no response. When asked about the proper frequency for Predictor Odds ratio 95% confidence interval P value
chest compressions, more (49.8%) said that they did not know and
Age .003
only 6.2% knew the correct frequency of 100 beats per minute. 18–39 Reference –
When asked about the proper site for chest compression, most 40–64 1.34 0.82–2.19
people (33.8%) responded that they would chose to compress in 65+ 3.00 1.54–5.84
the middle of the chest. Study subjects seemed unsure as what Income .014
<$30,000 1.68 0.77–3.64
they would do first in the case of a family member collapsing and $30,000–$50,000 .088 0.39–2.03
ceasing to breath. Approximately one third (32.7%) of the study sub- $50,000–$100,000 2.25 1.11–4.54
jects stated that they would begin by opening the airway, providing $100,000+ 0.96 0.38–2.41
two breaths, then performing 30 chest compressions, and repeat- Unspecified Reference –
ing while roughly another third (32.7%) would do nothing except
dial 911. Most subjects surveyed knew what an AED was (62.8%),
but most (68.0%) did not feel confident in using one. statistically insignificant during multivariate analysis because the
Based on univariate analysis, study subject variables associ- risk for a heart attack or cardiac related problems was associated
ated with knowledge of Hands-OnlyTM CPR were age (P = 0.01), with age. Further details from the multivariate analysis can be
prior personal heart related events (P = 0.008), and annual income found in Table 4. For willingness to perform Hands-OnlyTM CPR
(P = 0.01); further details regarding other predictors can be found in on a stranger, only family history of a heart attack and prior train-
Table 2. The greatest predictor of willingness of the participants to ing in CPR were significant predictors in the multivariate analysis
perform Hands-OnlyTM CPR on someone they did not know were (Table 5).
previous CPR training (P = 0.01) and a history of a cardiac related
event in the family (P = 0.003); more information can be found Table 5
in Table 3. We then performed multivariate analyses in which Multivariate association between predictor variables and willingness to perform
all variables, which had a univariate P-value of 0.20 or less were Hands-OnlyTM CPR on a stranger.
included in a stepwise logistic regression. Only age (P = 0.003) and Predictor Odds ratio 95% confidence interval P value
income (P = 0.014) remained as statistically significant predictors
Family history heart attack 1.85 1.20–2.86 .006
of knowledge of Hands-OnlyTM CPR. While a prior heart attack was
Any previous CPR training 1.82 1.15–2.88 .011
predictive of knowledge of Hands-OnlyTM CPR, this factor became
 J. Urban et al. / Resuscitation 84 (2013) 1574–1578 1577

Table 6 to perform Hands Only CPR on a bystander—once again emphasiz-

Univariate association between predictor variables and knowledge of Hands-OnlyTM
ing the importance of CPR training. This was validated in a study by
CPR—subjects without prior CPR training.
Bobrow et al., when the rate of bystander CPR increased from 19.6%
Predictor No. % Participants P value in 2005 to 75.9% after a large public education campaign in Hands-
who knew
Only CPR.22 Another prospective trial by Bobrow and colleagues of
about HO CPR
336 adults without prior recent CPR training found that laypersons
Age .49 exposed to an ultra-brief Hands-Only CPR training video of only
18–39 114 18.4
60 s were more likely to attempt CPR and demonstrated superior
40–64 144 24.3
65+ 41 24.4 CPR skills than untrained lay persons.15
Gender .76 Several prior studies are in agreement with our findings. A
Female 145 21.4 study conducted in Korea on laypersons’ willingness in performing
Male 153 22.9
bystander CPR found that BLS training increased laypersons’ confi-
Race .65
Caucasian 224 23.2 dence and willingness to perform bystander CPR on a stranger and
African American 21 19.0 that laypersons were more willing to perform Hands-OnlyTM CPR
Other/unspec. 56 17.9 than standard CPR on a stranger regardless of BLS training.23 Stud-
Education .53 ies from other countries have similarly found that most laypersons’
<High school 0 0
are reluctant to perform standard CPR, yet more willing to perform
High school 135 19.3
College 124 25.0 Hands-OnlyTM CPR on strangers.24–26
Graduate 39 23.1 An interesting finding of our study was that one’s own cardiac
Prior heart attack <.001 event was unrelated to willingness to do Hands-Only CPR on a
Yes 41 43.9
stranger, but a family member’s event was a predictor. We theorize
No 212 18.5
Family history heart attack .08
that this may be due to issues of denial or unwillingness to focus
Yes 171 25.7 on one’s own mortality. While this may be an anomaly, it suggests
No 128 17.2 that special efforts should be made to train friends and relatives of
Health related career .29 patients with a cardiac event to increase the likelihood of bystander
Yes 4 0
CPR. This recommendation is further supported by studies show-
No 297 22.2
Income .30 ing that bystander CPR is more common in relatives of victims of
<$30,000 57 21.1 cardiac arrest.27
$30,000–$50,000 53 13.2 Cardiac arrest is a major healthcare problem associated with
$50,000–$100,000 96 27.1
poor survival rates, in part due to limited and sometimes inef-
>$100,000 32 25.0
Unspecified 48 16.7
fective bystander CPR and efforts to improve the frequency and
effectiveness of bystander CPR are sorely needed. Introduction of
Hands-OnlyTM CPR has the potential to address some of these
3.1. Subjects without prior CPR training issues by simplifying CPR and reducing concerns regarding deliver-
ing mouth-to-mouth breathing. However, widespread adoption of
Approximately 42% of those interviewed had previously Hands-OnlyTM CPR will require major educational efforts to ensure
received training in CPR. It seems quite reasonable that these people that a critical mass of laypeople is knowledgeable of Hands-OnlyTM
would either not have heard of Hands-Only, or not consider using it. CPR. Given the simplicity of Hands-OnlyTM CPR, there may be a new
Therefore we analyzed only those subjects who did not have prior opportunity to train a large number of lay rescuers in relatively
CPR training with respect to their knowledge of Hands-Only CPR. short courses. A prospective trial of 336 adults without prior recent
Univariate analysis showed that only occurrence of a prior heart CPR training found that laypersons exposed to an ultra-brief Hands-
attack was significantly associated with knowledge of Hands-Only Only CPR training video of only 60 s were more likely to attempt CPR
CPR (Table 6). Stepwise logistic regression which included all vari- and show superior CPR skills than untrained lay persons.15 Other
ables with a univariate P value of 0.20 or less as potential predictors studies have similarly shown that older adults learned the funda-
resulted in only prior heart attack as a significant predictor. mental skills of CPR with a brief training program in about half
an hour.28 Finally, mere exposure to CPR training can have positive
4. Discussion effects on attitudes, even without live training by a BLS instructor.28

The results of the current study demonstrate that most subjects

surveyed were unaware of Hands-OnlyTM CPR currently recom- 4.1. Limitations
mended by the AHA for BLS among untrained responders to a
cardiac arrest. This is contrast to the Lee study in Korea21 and Our study has several major limitations. First, the study was con-
the outcomes study by Bobrow and colleagues.15 In both of these ducted at a single, mostly affluent suburban academic center that
instances focused training was done accompanied by regional pro- may not be representative of other settings or the general public.
motion. Second, our study conclusions are based on responses to survey
Since no specific local campaigns are underway our population questions and may not accurately reflect actual knowledge of or
would rely on the national efforts by AHA and other training organi- willingness to perform Hands-OnlyTM CPR. Finally, we recognize
zations to be familiar with Hands-Only CPR. This could be important that for the majority of adult victims, Hands-OnlyTM CPR is a good
to other communities who are attempting to increase knowledge solution for layperson training, however consideration should be
about Hands-Only CPR and hopefully increase its use. Grassroots given to a follow-up stage when ventilation is added to satisfy the
training and promotion will play a critical role in the promulgation needs of a minority victims.29
of Hands-Only CPR.
Despite this lack of knowledge, when informed of Hands-OnlyTM
CPR, most subjects responded that they would be willing to per- Conflict of interest statement
form Hands-OnlyTM CPR even on strangers with cardiac arrest. Of
note, subjects with pervious CPR training were even more willing The authors have no conflict of interest.
1578 J. Urban et al. / Resuscitation 84 (2013) 1574–1578

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