Project adam (Automated Defibrillators in Adam’s Memory) School Manual



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Project ADAM (Automated Defibrillators in Adam’s Memory)

School Manual

A Roadmap for Project ADAM School Coordinators



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Acknowledgments:


Project ADAM would like to acknowledge the following individuals for their contribution to this manual:

  • Sydney Allen, Quality Coordinator, Herma Heart Center

  • Kyle Herma, School Intervention Specialist, Herma Heart Center

  • Allison Thompson, Project ADAM Administrator, Herma Heart Center

  • Laura Friend, Project ADAM National Board Member

  • Jon Cohn, Fire Chief and Emergency Management Director, Greenfield, Wisconsin

  • Dan Tyk, Lieutenant and EMS Manager, North Shore Fire, Milwaukee, Wisconsin

  • The Frain Family and Morgan Frain, Project ADAM Survivor

  • Claire Crawford, Project ADAM Survivor

  • Maria Acevedo, Project ADAM Survivor

Project ADAM would like to acknowledge the affiliate program medical directors and coordinators around the country, and Alison Ellison who trained and supported our coordinators:

  • Project ADAM Wisconsin and National Headquarters, Children’s Hospital of Wisconsin Herma Heart Center

  • Alabama LifeStart, Children's Hospital of Alabama

  • Project ADAM Colorado, Children’s Hospital Colorado

  • Project ADAM Florida, Florida Hospital for Children

  • Project ADAM Inland Northwest, Sacred Heart Children’s Hospital

  • Project ADAM Michigan, C.S. Mott Children’s Hospital

  • Project ADAM Middle Tennessee, Monroe Carell Jr. Children's Hospital at Vanderbilt

  • Project ADAM Ohio, Nationwide Children's Hospital

  • Project ADAM Sacramento, U.C. Davis Children’s Hospital

  • Project ADAM Tennessee, East Tennessee Children’s Hospital

  • Project ADAM Texas, Cook Children’s Medical Center

  • Project ADAM Texas, Texas Children's Hospital

  • Project S.A.V.E., Children's Healthcare of Atlanta

  • Youth Heart Watch, Children's Hospital of Philadelphia

To Dr. Stuart Berger, the founding medical director of Project ADAM, thank you for your continued efforts to grow our mission throughout the country.

To Dr. Robert Campbell, co-national medical director of Project ADAM, thank you for your continued advocacy surrounding a practiced response to SCA in our schools and communities.

With the utmost respect and gratitude, a special thank you to the Lemels, Adam’s family. Without your passion and persistence none of this would be possible.

Table of Contents


Acknowledgments: 1

Section 1 – Building Momentum 3

Identifying a Project ADAM Coordinator 3

The Cardiac Chain of Survival 3

Manual Goals 4

Mission, Vision and Values 4

History 4

Current State 5

Personal Stories 5

Prevalence of Sudden Cardiac Arrest (SCA) 7

The Case for CPR-AED Programs in Schools 7

The Chain of Survival 8

Legislative Considerations 8

Section 3 – Project ADAM Structure 9

Project ADAM Tier Framework 9

Primary and Secondary Prevention of Sudden Cardiac Death 10

It Takes a Village 10

Section 4 – Program Implementation 12

Implementation Tools 15

Attachments 16



References 16







Section 1 – Building Momentum


Since 1999, Project ADAM affiliate programs have provided schools with the resources necessary for planning and implementing school cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) programs. The goals of the planning manual address the needs of Project ADAM coordinators as they work toward achieving a fully functioning school-based CPR-AED program in partnership with Project ADAM. These goals may be shared with school administration and community members who have a vested interest in the outcomes of a program that aims to prevent sudden cardiac death.

Identifying a Project ADAM Coordinator


To build a sustainable school program it is critical to identify an individual willing to serve as the Project ADAM coordinator. Once the coordinator is identified, he or she can utilize this school manual to tailor the program to the needs of his or her school.

The Cardiac Chain of Survival


Project ADAM programs help schools implement the following crucial steps to enhance the survival of sudden cardiac arrest.

chain of survival graphic.png

Based on the American Heart Association’s Out-of-hospital chain of survival.

Manual Goals


After reviewing this Project ADAM School Manual, you should be able to:

  1. Define Adam’s story along with the mission, vision, and values of Project ADAM.

  2. Define the need for coordinated Project ADAM programs as immediate first responders to sudden cardiac arrest (SCA) in schools.

  3. Describe the three tier system used to identify a school’s stage of readiness to respond to a sudden cardiac emergency.

  4. Establish a sustainable program implementation process with the outlined structure recommendations, resources, and local affiliate support.

Mission, Vision and Values


Mission: Project ADAM saves lives.

Vision: Project ADAM is a national, non-profit organization committed to saving lives through advocacy, education, preparedness and collaboration to prevent sudden cardiac death. Focused prevention training and education ensures schools and communities are not only equipped, but trained in prevention of sudden cardiac death.

Values:

  • Advocacy: Focus on legislative advocacy and awareness to strengthen the cardiac chain of survival in our communities.

  • Education: Provide initial, re-certification, and train the trainer guidance and mentorship to our constituents.

  • Preparedness: Commit to developing and supporting equipment placement, staff training and implementation of practiced cardiac emergency response plans in schools.

  • Collaboration: Commit to building necessary partnerships at the state and national level to implement and sustain comprehensive CPR-AED programs.

  • Memory: Improve the cardiac chain of survival in schools and communities in memory of Adam Lemel, a 17-year-old Whitefish Bay, WI, high school student who collapsed and died while playing basketball at school.

History


 In 1999, 17-year-old Adam Lemel was playing basketball in Whitefish Bay, Wis., when he collapsed and died. Adam had suffered a sudden cardiac arrest, meaning his heart suddenly stopped pumping blood to the rest of his body. His life could have been saved through the use of an automated external defibrillator (AED), but one was not available that day.

Adam's parents, Patty Lemel Clanton and Joe Lemel, collaborated with Children's Hospital of Wisconsin to create this program in Adam's memory.

I want to live a life I can be proud of.” Adam wrote this in his 8th grade autobiography. It seemed at 14 years old Adam understood the meaning of life. He did live a life he could be proud of and through Project ADAM he continues to. The spirit of Adam lives on through Project ADAM, making a positive impact on the world, helping save the lives of countless others and helping schools become a safer place through cardiac emergency preparedness and awareness.

-Patty Lemel Clanton, Adam’s Motheradam for manual.jpg

Current State


From 1999 to 2016, over 100 staff and students who suffered sudden cardiac arrest on school property were saved because their schools had a practiced CPR-AED program in partnership with Project ADAM.

Project ADAM currently has 13 affiliate sites in 12 states that bring resources and expertise to schools across the country. The vision of supporting school CPR-AED implementation efforts through Project ADAM has spread to Alabama, California, Colorado, Florida, Georgia, Michigan, Ohio, Pennsylvania, Tennessee, Texas and Washington.


Personal Stories


The impact Project ADAM has had on schools and communities across the country is invaluable. Below are three stories that highlight the importance of bringing comprehensive CPR-AED programs to schools and communities throughout the nation.

Mariamaria_2015.jpg

In 2010 at the age of 11, Maria suffered a sudden cardiac arrest and collapsed in her school classroom. The teacher immediately called for help and staff started CPR. Meanwhile, an AED was being retrieved from within the school. Staff applied the AED pads to Maria’s chest but no shock was initially advised so chest compressions were continued. With the pads still attached to her chest, the AED detected a shockable rhythm and a shock was delivered. When emergency medical services (EMS) arrived they administered several additional shocks to revive her. She was then transported to Children’s Hospital of Wisconsin where the Herma Heart Center managed her follow-up care. The quick actions of the school staff prior to the arrival of EMS resulted in a successful resuscitation within Milwaukee Public Schools, a Project ADAM partner school district. Maria is now a freshman in college and a Project ADAM advocate.

Morgan

3 year old Morgan Frain was having dinner with her family at Lambeau Field in Green Bay, Wisconsin. She got up to get a drink and suddenly collapsed. Her parents quickly turned her over and noticed she was turning blue. Her mom began CPR while her sister helped to call 911. As her mom continued CPR they yelled for an AED. A Green Bay Packer security officer quickly arrived with an AED from within the stadium. Morgan’s father applied the pads to his daughter’s chest and a shock was delivered and she had regained consciousness prior to the arrival of EMS. Thanks to community awareness of CPR trained individuals and publicly placed AEDs, Morgan is with us today.morgan1.jpg

It was later found out that Morgan’s sudden cardiac arrest occurred as a result of a rare genetic heart disorder. To help prevent future catastrophes for other children and their families, Morgan's family started a local foundation and partners with Project ADAM to help support CPR and AED programs in local Wisconsin schools.

Claire07_6660_full.jpg

High school volleyball player, Claire, had just sent a serve over the net when she grabbed her chest, then collapsed to the floor. She wasn’t breathing and her heart wasn’t beating. Fortunately for Claire, her school had worked with Project S.A.V.E., an affiliate program of Project ADAM, to train members of its staff in the use and maintenance of AEDs. Immediately after Claire’s cardiac arrest, one of those teachers grabbed the nearest AED and used it to save her life. Two and a half minutes after her heart stopped, Claire received a shock from the AED. Eleven minutes after she fell, paramedics arrived to take her to the hospital. There, doctors told her parents that because of her specific condition, CPR alone would not have revived her. The paramedics would have been too late. Claire’s heart needed a shock to get it working and in rhythm again—a shock that only came in time because her school was prepared and had a plan for a cardiac emergency.

Section 2 - Scope of the Issue


Prevalence of Sudden Cardiac Arrest (SCA)


The Institute of Medicine’s (IOM) 2015 report Strategies to Improve Cardiac Arrest Survival, estimates that “more than 1,600 people suffer a cardiac arrest every day in the United States, defining an immense and sustained public health problem” (Institute of Medicine, 2015, p.13).

State and local departments of health and education, and leading organizations in cardiac arrest response and treatment, should partner with training organizations, professional organizations, public advocacy groups, community and neighborhood organizations and service providers, and local employers to promote public awareness of the signs, symptoms, and treatment of cardiac arrest. These efforts require public cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training across the lifespan, creating a culture of action that prepares and motivates bystanders to respond immediately upon witnessing a cardiac arrest” (Institute of Medicine, 2015, p. 13).

Within the IOM’s strategic report, five recommendations are identified to improve the outcomes of sudden cardiac arrest. Project ADAM is currently focused on the following two recommendations:


  • Establish a national registry of cardiac arrest in order to monitor performance in terms of both success and failure, identify problems, and track progress.

    • Project ADAM affiliate programs and schools support efforts toward a national registry and strive to track cardiac events in the schools we serve.

  • Educate and train the public in CPR, use of automated external defibrillators, and EMS-system activation.

    • Project ADAM affiliate programs and schools work toward implementing coordinated CPR-AED programs in schools.

See Attachment: Institute of Medicine, Strategies to Improve Cardiac Arrest Survival: A Time to Act, Report Brief

The Case for CPR-AED Programs in Schools


In developing Cardiac Emergency Response Planning for Schools: A Policy Statement, the American Heart Association sought the expertise of representatives across many partner organizations. In 2016, a collaborative policy statement was published.

Schools partnering with Project ADAM will aim to achieve the following recommendations within this policy supported by the American Heart Association:



  • Establishing a Cardiac Emergency Response Team

  • Activating the team in response to an SCA

  • Implementing AED placement and routine maintenance within the school (similar to fire-extinguisher protocols)

  • Disseminating the plan throughout the school campus

  • Maintaining ongoing staff training in CPR/AED use

  • Practicing using drills (akin to fire and lock-down drills)

  • Integrating local EMS with the plan

  • Reviewing and evaluating the plan on ongoing and annual basis

A sudden cardiac arrest in school or at a school event is potentially devastating to families and communities. An appropriate response to such an event—as promoted by developing, implementing, and practicing a cardiac emergency response plan (CERP)—can increase survival rates. Understanding that a trained lay-responder team within the school can make a difference in the crucial minutes between the time when the victim collapses and when emergency medical services arrive empowers school staff and can save lives” (Rose et al., 2016, p. 263).

See Attachment: Cardiac Emergency Response Planning for Schools: A Policy Statement

The Chain of Survival


Project ADAM affiliate programs aim to support schools with the implementation of the Cardiac Chain of Survival. Since survival rates decrease by 10% with each minute of delayed defibrillation, the chain of survival is designed to minimize the time between arrest and defibrillation and increase survival. The following five steps comprise the chain of survival:

  1. Early recognition of sudden cardiac arrest (SCA)

  • Collapsed and unresponsive

  • Gasping, gurgling, snorting, moaning or labored breathing

  • Seizure-like activity

  1. Early Access to 911

  • Confirm unresponsiveness

  • Call 9-1-1 and follow emergency dispatcher’s instructions

  • Call any on-site emergency responders

  1. Early CPR

  • Begin cardiopulmonary resuscitation (CPR) immediately

  1. Early Defibrillation

  • Immediately retrieve and use an AED to restore the heart to its normal rhythm

  1. Early Advanced Care

  • Emergency medical services (EMS) responders begin advanced life support and transfer to a hospital

Based on the American Heart Association’s Out-of-hospital chain of survival.

Legislative Considerations


Good Samaritan Law

Nationally, the lay rescuer is protected under the Good Samaritan Law. Elements of the Good Samaritan Law may vary from state to state, however are uniformly in place to encourage bystanders to act in a situation where a person is unresponsive. The most common misperception is that a rescuer can harm a victim by inadvertently delivering a shock to the heart. An AED is a safe device, one that has been tested by the manufacturer and approved by the Food and Drug Administration (FDA) to appropriately detect ventricular fibrillation in both children and adults. Therefore, CPR-AED training and use of this device only can enhance lay rescuers’ efforts to attempt to provide the best possible care in an emergency.

In addition, each state has common laws (based on case law or precedent) that may pertain to standards of care and civil liability. Some laws may penalize those who fail to respond. It is best to have legal counsel review the school’s CERP in the context of federal and state laws, including specific laws providing legal protection for lay rescuers within their jurisdiction” (Rose et al., 2016, p. 268).

CPR-AED Related Legislation

Some states mandate CPR and AED training for school staff, and AED placement in schools. Once legislation has been passed, it is more likely the state has worked to implement measures to support schools in attaining proper training and AED placement.



SCA Awareness and Plans

States have begun to pass legislation requiring schools to educate their staff on the warning signs of sudden cardiac arrest, and to have a written plan and protocol outlining the action steps a school will take in the event of a cardiac emergency.



Project ADAM Legislation

In 2015, Tennessee was the first state to pass legislation requiring schools to complete an annual Project ADAM cardiac emergency response drill. We hope to grow this type of legislation to states across the nation to promote the necessity of implementing annual cardiac emergency response drills in schools.



See up-to-date CPR-AED legislation in Project ADAM affiliate states by going to our national website, www.projectadam.com

Section 3 – Project ADAM Structure

Project ADAM Tier Framework


The Project ADAM framework for school readiness in response to sudden cardiac arrest uses three tiers to describe the appropriate levels of program strategy support, with the goal of working towards the top of the pyramid to achieve Project ADAM Heart Safe Schools Designation.

Tier I indicates the school does not have an AED. Emphasis is placed on identifying funding opportunities, appointing a Project ADAM coordinator and educating school staff on the importance of CPR and AEDs in the school setting.

Tier II indicates the school has an AED(s), but has not achieved Project ADAM Heart Safe Schools designation. The school will focus on initiating regular cardiac emergency response drills and enhancing communication and training opportunities.

Tier III indicates the school has achieved Project ADAM Heart Safe Schools designation. This includes accessible AEDs, CPR-AED trained staff and a written and practiced plan to respond to SCA.

Note: To assess which tier your school is in, complete the Heart Safe Schools Checklist (located on the Project ADAM website in the Preparedness section) and discuss next steps with your local Project ADAM affiliate.

Primary and Secondary Prevention of Sudden Cardiac Death


In order to effectively combat sudden cardiac death in schools, Project ADAM recommends both primary and secondary prevention tactics.

Primary prevention (prior to SCA occurring) includes:



  • Staff awareness of early warning signs of a sudden cardiac event.

  • Use of a pre-participation sports physical exam, such as the one endorsed by the American Academy of Pediatrics (AAP).

Secondary prevention is also crucial because sudden cardiac events often occur without recognition or warning. Prompt CPR and use of an AED play a vital role in the survival of victims of sudden cardiac events.

Secondary prevention (upon SCA occurring) includes:



  • Staff and student CPR-AED training.

  • Accessible and maintained AEDs throughout the school campus.

It Takes a Village


Project ADAM recommends including a number of key school, medical and community partners in order to implement and sustain a successful program.

Project ADAM Coordinator

To build a sustainable school program it is critical to identify an individual willing to serve as the Project ADAM coordinator. This person can be a:



  • School nurse

  • Athletic director

  • Athletic trainer

  • Physical education teacher

  • Teacher

  • Administrator

  • Other willing individual


Note: The coordinator should be in the school consistently (for example, if not full-time, at least on a weekly basis) in order to ensure the program’s efficacy.
Key responsibilities (in partnership with a dedicated team):

  • Development of program budget

  • Creation of a cardiac emergency response team

  • AED maintenance

  • Facilitation of annual cardiac emergency response drills

  • Up-to-date CPR-AED training

  • Consistent communication with local Project ADAM affiliate program

We recommend connecting with your local Project ADAM affiliate as you work through the planning and implementation steps. Promptly notify your local Project ADAM affiliate of any events where the AED is used.

Cardiac Emergency Response Team

Create a team within your school made up of at least 10% of the school’s staff that will respond in the event of a cardiac emergency by activating the chain of survival.

This team will also commit to participating in at least one cardiac emergency response drill per year so that a practiced plan is in place if a cardiac emergency occurs. Contact your local Project ADAM affiliate for support in implementing drills.

Team members may include:



  • Custodial staff

  • Athletic trainer

  • Athletic director

  • Coach

  • Teacher

  • School nurse

  • Parent

  • Student

  • Administration

Key responsibilities:

  • Up-to-date CPR-AED training

  • Participate in at least one cardiac emergency response drill annually

  • Commit to regular meetings with the team to improve response and communication

Medical Director

Your school CPR-AED program will require the appointment of a volunteer medical director. Project ADAM recommends a medical director within your state or local community, and connection to a hospital system. The medical director should be involved in the entire program planning process and should be well versed in the signs, symptoms and treatment for sudden cardiac arrest.


Fire and Emergency Medical Services (EMS)

Create a relationship with your local fire and/or emergency medical services (EMS) organization as they are a critical link to your Project ADAM program. 

Fire and EMS representatives may be able to assist with:


  • AED purchasing

  • Determining AED locations

  • Developing and practicing your cardiac emergency response plan

When your policies and procedures for your cardiac emergency response plan are complete, submit the plan to these same fire and EMS representatives so they are aware of the school’s plan and program.

Fire and EMS organizations are generally traditional and have functioned as the sole provider of out of hospital care.  Progressive Fire and EMS organizations understand that during a cardiac arrest even the best responses need the help of bystanders prior to the arrival of EMS and Paramedics.  Fire and EMS are trusted and respected organizations in our communities but they must be committed to partnering with others to improve sudden cardiac arrest outcomes.  Go out and find the right champion (they may not always be at the top of the organization but they exist) in local Fire and EMS organizations as the benefits are synergistic to all.”

Jon Cohn, Fire Chief and Emergency Management Director, Greenfield, Wisconsin

Once key roles and partners have been identified, your school is ready to utilize the program implementation section of this manual.








Section 4 – Program Implementation


There are many steps to think about when building a school CPR-AED program in partnership with Project ADAM. The following timeline describes a general plan of action to guide the Project ADAM coordinator. It may take anywhere from 6-12 months to get your program up and running. Connect with your local Project ADAM affiliate for support.  

All up-to-date implementation documents can be found and downloaded on our website: www.projectadam.com/preparedness



Implementation Timeline

Program Planning and Maintenance (Steps 1-7)

Step 1

  • Identify a Project ADAM coordinator.

Selecting a dedicated point person to lead organizational efforts is an instrumental step in creating and maintaining a functional and sustainable program.


  • Acquire rough estimates for AED equipment.

Securing funding may take some time if it is not already in your school budget.


  • Create an annual budget.

This will help track equipment, training and maintenance costs of the program and should be shared with administration.
*Relevant documents: Fundraising Tools and Budget Template.

Step 2

  • Conduct an AED site assessment.

The AED should be accessible to a victim in less than 2 minutes from any point in the school. Local Fire and/or EMS organizations are often willing to help conduct the assessment.


  • Identify a program medical director.

Contact your local Fire, EMS, hospital or Project ADAM affiliate to help identify a qualified individual.
* Relevant documents: AED Site Assessment and Medical Director Checklist.

Step 3

  • Finalize the AED unit make and make and model.

Identify a vendor to order the unit and contact your local Project ADAM affiliate for support.
*Relevant document: Choosing an AED.
Step 4

  • Purchase AED unit(s).




  • Create a school cardiac emergency response plan.

A cardiac emergency response plan (CERP) is a written document that establishes specific steps to take action in a cardiac emergency in a school setting.  In 2015, Project ADAM partnered with the American Heart Association and other invested organizations to create a response plan template based on best practices.
*Relevant documents: Written Plan for SCA in Schools - Full Version,

Written Plan for SCA in Schools – Partner School, Written Plan for SCA in School Athletics.
Note:

  • Refer to Written Plan for SCA in Schools - Full Version, for the complete version of the CERP. This document can be edited to fit the school's needs.

  • Project ADAM coordinators may refer to Written Plan for SCA in Schools – Partner School as an example of how a Project ADAM partner school tailored the plan to fit the school's needs.

  • Engage athletic staff by referring to the Written Plan for SCA in School Athletics to plan for venue-specific events.

Step 5

  • Create a cardiac emergency response team.

This team is comprised of at least 10% of school staff and is expected to keep up-to-date CPR-AED training. Members will also participate in at least one cardiac emergency response drill per year.


  • Secure a plan for training or certifying staff.

The Project ADAM coordinator will create a plan for staff CPR-AED training and renewal, at minimum every two years. A review of the school’s plan for SCA, AED location and team members should also be reviewed at this time.
*Relevant documents: CPR-AED Training Tools.

Note:

  • The cardiac emergency response team members should be listed and kept up-to-date within the Written Plan for SCA in Schools.


Step 6

  • Secure school CPR-AED training equipment.

Secure CPR training manikins (a 2:1 ratio for staff) and at least one AED training unit for practicing the school’s response.


  • Develop a plan for maintaining the school’s AED equipment.

  • Develop a plan for debriefing if the AED is used.


*Relevant documents: AED Maintenance and AED Incident Debriefing.

Step 7

  • Conduct a staff CPR-AED training.




  • Mount AED(s) at school.




  • Share the complete written cardiac emergency response plan.

Refer to Step 4 for tips on completing this plan. This should be shared with your medical director, cardiac emergency response team and local Fire and/or EMS.


  • Conduct a cardiac emergency response drill.


*Relevant document: Cardiac Emergency Response Drills.
Sharing Your Program

Step 8

  • Stay in touch with your local Project ADAM affiliate program.

Contact your local affiliate for ongoing program support, report incidents when the AED is used and share an annual summary of your program with your local affiliate.


  • Work towards the Heart Safe Schools designation with Project ADAM.

Contact your local Project ADAM affiliate for support.
*Relevant documents: Project ADAM CPR-AED Incident Report, Partner School Summary and Heart Safe Schools Checklist and Project ADAM Acknowledgement.


Implementation Tools


All up-to-date implementation documents can be found and downloaded on our website: www.projectadam.com/preparedness

Program Planning and Maintenance

Implementation Timeline

Fundraising Tools

Budget Template

AED Site Assessment

Medical Director Checklist

Choosing an AED

Written Plan for SCA in Schools – Full Version

Written Plan for SCA in Schools – Partner School

Written Plan for SCA in School Athletics

CPR-AED Training Tips

AED Maintenance

AED Incident Debriefing

Cardiac Emergency Response Drills

School-Based Drill Scenarios
Sharing Your Program

Project ADAM CPR-AED Incident Report

Partner School Summary

Heart Safe Schools Checklist

Project ADAM Acknowledgement

Attachments


  • Institute of Medicine, Strategies to Improve Cardiac Arrest Survival: A Time to Act, Report Brief

  • Cardiac Emergency Response Planning for Schools: A Policy Statement


Attachments can be accessed on our website, www.projectadam.com/preparedness

References


IOM (Institute of Medicine). 2015. Strategies to improve cardiac arrest survival: A time to act. Washington, DC: The National Academies Press.
Rose et al. (2016). Cardiac Emergency Response Planning for Schools: A Policy Statement. NASN School Nurse 31(5), 263-270. Doi: 10.1177/1942602X16655839.



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Project ADAM National Affiliates, Updated November 2016



For an up-to-date version, please visit www.projectadam.com




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