Despite a growing number of states requiring high school students to learn cardiopulmonary resuscitation (CPR), nearly 700,000 students graduate each year without receiving training due to lack of legislation, according to a review published in the Journal of the American College of Cardiology.

“This represents a missed opportunity to equip our population with this crucial skill,” wrote lead author Lorrel E. Brown, MD, with the University of Louisville School of Medicine, and colleagues.

As of September 2017, 39 states had legislation requiring CPR in training in high schools, with all but one requiring hands-on training. However, there is no standardized training program and currently only 8 percent of those states require the instructor to be certified to teach CPR, according to Brown et al.

Out-of-hospital cardiac arrest (OHCA) affects more than 350,000 people each year in the U.S. Bystander CPR has been proven to boost survival rates following OHCA, but geographic disparities exist in the response to CPR.

Because previous training increases bystanders’ willingness to perform CPR, the Institute of Medicine identified high schools as a prime setting to address this gap. High schools are centrally organized and are currently educating more than 16 million people, representing a large audience for CPR training, Brown and colleagues wrote.

“By requiring high school students to receive training before graduation, we are creating a group of potential lifesavers each year,” they wrote. “School CPR training has contributed to increased community rates of bystander CPR in Norway, Denmark, and Minnesota. From these locations we learned that implementing CPR training in schools is most effective when it is undertaken as a societal responsibility, rather than the responsibility of the medical profession.”

For their review, the researchers surveyed high schools in 32 states. A total of 424 (1.7 percent) completed the survey—96 percent of them public schools and 3 percent private schools.

Most schools reported using a CPR-certified instructor, but 11 percent reported using a non-certified teacher or coach. Ninety-six percent used hands-on CPR practice as part of their training and 63 percent reported automated external defibrillator training. The researchers noted response variation occurred even among schools from the same state.

“As no gold standard currently exists, it is not surprising that no standard method is being used in high schools,” Brown and colleagues wrote. “It is noteworthy that only 8 percent of state laws require the instructor to be certified to teach CPR, raising questions as to the quality of CPR teaching.”

The researchers said future studies are needed to determine “the most effective teaching method that leads to long-term CPR skill retention, which would allow for standardization of CPR training in U.S.”