Even if a community has done everything possible to strengthen its chain of survival, emergency responders can only do so much. The time to first shock for victims of sudden cardiac arrest (SCA) may be delayed in rural areas, where emergency medical services (EMS) have to travel long distances, and in urban areas, where EMS has to contend with traffic and high-rise buildings. This is why many locations—such as airports, office complexes, industrial complexes, residential communities, shopping centers, entertainment centers, sports centers, transit centers and schools—have established on-site CPR-AED programs.
How Do You Know Whether You Need An On-Site CPR-AED Program?
Here are some criteria to consider:
- Is it unlikely that the local EMS system would be able to reliably achieve a “call-to-shock” interval of five minutes or less at this site?
- Has an SCA incident occurred at this site in the past five years and have the demographics of the population served at this site remained relatively constant?
- Does this location have an at-risk population?
- Is this location considered a higher-risk location?
- Can an active, hands-on medical director be identified for this location?
- Does this location have personnel willing and able to respond to cardiac emergencies to provide CPR and defibrillation?
If the answer to each of these questions is "yes," then it may be wise to consider implementing an on-site CPR-AED program.
Sudden cardiac arrest occurring outside the hospital is almost always unexpected. It can happen to anyone, any time, regardless of age, race or gender. However, some people are at greater risk than others. Here are some factors that increase individual risk:
- Men age 40 or older
- Post-menopausal women
- High blood pressure
- High cholesterol
- Sedentary lifestyle
- Personal history of heart disease
- Family history of heart disease
New research indicates that the following are predictors of sudden death:
- A resting heart rate of more than 75 beats per minute
- An increase in heart rate during exercise of less than 89 beats per minute
- A decrease in heart rate of less than 25 beats per minute after stopping exercise.
When sudden cardiac arrest occurs outside the hospital, it occurs most often in the home (57-75% of cases). For this reason, families of some at-risk individuals have elected to place AEDs in their homes and to be trained in CPR and AED use.
A number of studies have looked at the frequency in public locations (i.e., not in private residences) with variable results. Most studies seem to indicate that the majority of non-residential events occur as isolated events. As a result, it is difficult to predict where sudden cardiac arrest will occur in the future.
Nevertheless, these studies have identified locations that seem to have a higher incidence of sudden cardiac arrest. These include:
- Community/ senior citizen centers
- Dialysis centers
- Doctors’ offices (cardiology, internal medicine, family medicine and urgent care centers)
- Ferries/ train terminals
- Gaming establishments
- Golf courses
- Health centers/ gyms
- Homeless centers
- Large industrial sites
- Large shopping malls
- Nursing homes
- Sports/ events complexes
- Streets and highways
Lessons from the Public Access Defibrillation Trial: Adding AEDs doubles survival
A large study conducted between 2000 and 2003 in 24 locations in the U.S. and Canada, the Public Access Defibrillation (PAD) Trial, found that twice as many people survive SCA in locations with lay responders trained and equipped with AEDs and CPR than if they were trained in CPR alone.
The study compared outcomes from SCA in two settings:
- Locations with emergency response plans relying on laypersons as responders trained in CPR, and
- Locations with emergency response plans relying on laypersons as responders trained in CPR and AED use and equipped with AEDs.
More than 19,000 volunteers were trained at 993 locations, which were randomly assigned to either arm of the study. Locations included both multi-unit residential (14%) and public (86%) venues, such as recreational facilities, shopping centers, entertainment complexes, community centers and large office buildings. Training was conducted to meet competency standards of the American Heart Association.
The study found that a victim of SCA was twice as likely to survive at an AED site as at a CPR-only site (30 survivors in 496 units with AEDs versus 15 in 497 units that did not have AEDs). This result was statistically significant, and was largely due to improved survival in public locations. No difference was found in the residential sites. Ninety percent of survivors in each group had normal functional status or only mild impairment at hospital discharge.
Other key findings were:
- Using traditional definitions, the survival rate at public (as opposed to residential) AED sites was about 40% for treated patients.
- No inappropriate shocks or other serious adverse events related to patients occurred.
- The rate of ventricular fibrillation/ventricular tachycardia (rhythms treatable by defibrillation) at AED sites was 58%, higher than had been reported in previous studies.
The PAD Trial demonstrates that trained laypersons can use AEDs safely and effectively. Adding AEDs to public venues with structured on-site response plans doubled the number of survivors of sudden cardiac arrest.
The Public Access Defibrillation Trial Investigators. Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest. N Engl J Med 2004;351:637-46.
How to Set Up an On-site CPR-AED program: 10 Tips for Success
1. Identify Program Leadership
This includes, at a minimum:
- A medical director, who can be either a physician or another qualified healthcare provider responsible for program oversight
- A program director, responsible for oversight of day-to-day operations
- A representative of the local EMS system.
2. Review Laws, Regulations and Advisories
A number of federal and state laws, regulations and advisories address AED programs. These are summarized below.
Federal Laws, Regulations and Advisories
- The Aviation Medical Assistance Act (Public Law 105-170) declares that air carriers and individuals "shall not be liable for damages" in attempting to obtain or provide assistance. Administrative rules proposed by the FAA as required by this law would mandate that every commercial aircraft be equipped with specified life-saving equipment and appropriately stocked first-aid and medical kits, including AEDs, and that flight crew members be trained in their use.
- The Cardiac Arrest Survival Act (Public Law 106-505) addresses placement of AEDs in federal buildings and provides civil immunity for authorized users. It provides immunity for Good Samaritans, building owners, and renters who act in good faith to purchase or use an AED to save a life. The law does not preempt state laws on immunity.
- The Community Access to Emergency Devices Act (Community AED Act) (Public Law 107-188) authorized federal grants for the purchase and placement of AEDs in public places where cardiac arrests are likely to occur and for training first responders. The bill also encouraged private companies to purchase AEDs and to train employees in CPR and emergency defibrillation.
- The Federal Drug Administration (FDA) regulations requires that a physician must write a prescription for an AED (CFR 801.109) in order for an entity to purchase the device, with the exception of one model that has been cleared for purchase without a prescription. (http://www.fda.gov/cdrh/consumer/AED_PAD.html.)
- A Government Accounting Office (GAO) report recommends cardiac arrest data collection.
- An Occupational Health and Safety Administration (OSHA) advisory recommends AED placement at the workplace. (AED-card.pdf)
- The Rural Access to Emergency Devices Act, or Rural AED Act, section 413(a) of the Public Health Improvement Act (Public Law 106-505) awards grants to community partnerships in rural areas for the purchase of AEDs and for AED training (http://ruralhealth.hrsa.gov/funding/aedact.htm).
All 50 states have laws and/or regulations that address AED use. According to the National Council of State Legislatures, many state laws:
- Establish legislative intent that an "automatic external defibrillator may be used by any person for the purpose of saving the life of another person in cardiac arrest"
- Encourage or require training in the use of AED devices by potential users
- Require AED devices to be maintained and tested to manufacturer's standards
- Create a registry of the location of all such defibrillators, or notification of a local emergency medical authority
- Authorize a state agency to establish more detailed requirements for training and registration
- Allow a "Good Samaritan" exemption from liability for any individual who renders emergency treatment with a defibrillator.
“Good Samaritan” provisions are intended to provide immunity for certain AED program participants, such as AED medical directors, program directors, device acquirers, and users. However, the extent to which these laws provide actual immunity protection varies for program participants from state to state. For example, in some states, only trained rescuers are offered immunity protection; in others, any willing rescuer is protected.
For more information about laws affecting on-site AED programs, see http://www.ncsl.org/programs/health/aed.htm.
3. Determine Program Costs and Develop a Budget
On-site AED program costs include:
- Training (About $75-100 per person for formal training)
- AED(s) (List price for AEDs in 2006 range from approximately $1000 to $3500 each; discounts commonly are offered for volume purchases)
- Electrodes (adult and pediatric)
- Ancillary equipment (pocket CPR mask, razor, scissors, non-latex gloves, towel)
- Storage cabinets
- Salaries of program personnel
- Maintenance (AEDs require little maintenance, but someone needs to check devices and supplies on a regular basis).
Develop a budget that can be provided to potential program sponsors.
4. Secure Program Funding
Many on-site programs are funded through the organization’s operational budget. Sometimes, outside funding sources are needed. These can include:
- Local corporations and corporate foundations
- Local civic organizations
- Hospital foundations
- Public charities
- Government grants
- Traditional fundraisers.
5. Select an AED Brand and Model and Determine the Number of AEDs Needed
When determining the number of AEDs to purchase, consider the following: Since the goal is to treat SCA victims with a defibrillator within three minutes of collapse, AEDs should be placed in locations that can be reached within 90 seconds by potential responders walking at a fast pace from the victim to the AED.
When determining the location of AEDs, be sure to keep the devices in visible, secure locations that are readily accessible. Locations could include:
- Security guard station
- Main reception area
- Main corridors
- Near elevators.
For information on devices, see AED brands.
6. Recruit and Train Likely Responders
While AEDs are computerized devices that provide audio and visual prompts and have been used effectively by laypersons with little or no training, it is advisable nonetheless for potential responders to undergo training, not only so responders are familiar with the specific device that will be used in the on-site program, but also to ensure they know how to provide cardiopulmonary resuscitation (CPR).
Potential responders should undergo periodic refresher training. Program planners should plan to periodically train new recruits to address inevitable turnover among potential responders.
The following organizations provide CPR-AED training:
- American Heart Association: www.americanheart.org
- American Red Cross: www.redcross.org
- American Safety and Health Institute: www.ashinstitute.org
- Emergency Care and Safety Institute: www.ecsinstitute.org
- Initial Life Support Foundation www.ilsf.info
- National Safety Council: www.nsc.org
- Medic First Aid International: www.medicfirstaid.com
7. Develop a Plan for Emergency Communications
A plan for both internal and external emergency communications should be established to ensure that:
- On-site responders are summoned immediately
- 9-1-1 or the local emergency number is called immediately.
This plan should be developed in consultation with the local EMS system.
Internal notification options could include:
- Alarm that is activated when AED is removed from its cabinet
- Overhead paging system or intercom
- E-mail or instant message notification
- Pagers for trained responders
- Phone tree.
8. Develop, Practice and Follow a Written Response Plan
The written response plan should:
- Be coordinated with the local EMS system
- Identify and train likely rescuers, taking into account the need for refresher training and potential responder turnover
- Specify team member roles
- Place AEDs strategically to ensure timely response
- Ensure that basic instructions for AED use are placed with the AEDs
- Ensure that signs are placed in strategic locations to notify potential responders about AED locations
- Address internal and external emergency communications
- Address routine inspection of AEDs, electrodes, batteries and ancillary equipment
- Address periodic emergency SCA response drills (similar to fire drills)
- Address post-event review and feedback, including analysis of response plan effectiveness, rescuer performance, and AED function.
9. Cultivate Awareness About the Program
Program planners should inform all employees about the on-site AED program through such means as:
- Staff meetings
- Signs and posters
- Speaker luncheons
- Paycheck flyers.
To further awareness of the program among customers and other visitors, the following should be considered:
- Signs at entries to indicate the site is protected by an emergency response plan for
SCA (e.g., “AED on site”)
- Signs to indicate location(s) of AED(s)
- Posters with basic instructions for AED use
- Promotion of the site to the local media as one that demonstrates its concern about the safety
of its employees, customers and other visitors by implementation of an on-site AED program.
10. Institute Measures for Continuous Quality Improvement
After an emergency, the medical director and program director should:
- Review the case with the responder(s), offering constructive feedback and support
- Reevaluate the response plan for effectiveness and revise as necessary
- Share event data with state and local EMS agencies
- Ensure that the AED is returned to service with appropriate supplies as quickly as possible.
On-site CPR-AED programs that address these considerations should reap cost-effective life-saving benefits.