Position Statements

Position Statements

The following position statements from national associations support cardiopulmonary resuscitation and early defibrillation initiatives.

American College of Emergency Physicians
American College of Emergency Physicians
American College of Occupational and Environmental Medicine Guidelines on Automated External Defibrillation
American Heart Association
The American Red Cross
Canadian Association of Emergency Physicians Public Access Defibrillation Working Group
Citizen CPR Foundation
Emergency Care Research Institute
Emergency Care Research Institute/ Healthcare Risk Control
Heart & Stroke Foundation of Canada ECC Coalition Task Force
International Association of Chiefs of Police and International Association of Fire Chiefs
International Association of Fire Fighters
International Liaison Committee on Resuscitation
National Association of EMS Physicians
National Association of EMS Physicians
The National Association of State Emergency Medical Services Directors
National Council of State EMS Training Coordinators, Inc.
National Fire Protection Association (NFPA) 1710 Standards
National Heart, Lung and Blood Institute
American Association of Occupational Health Nurses (AAOHN)

American College of Emergency Physicians

Public Training in Cardiopulmonary Resuscitation and Public Access Defibrillation

Revised and approved by the ACEP Board of Directors January 2006

This policy statement was originally approved by the ACEP Board of Directors April 1984, titled "Public Training in CPR" and was revised and approved by the ACEP Board of Directors October 1994. The original policy statement was replaced September 1999 by the policy statement titled "Public Training in Cardiopulmonary Resuscitation and Public Access Defibrillation."

The American College of Emergency Physicians (ACEP) supports and strongly encourages cardiopulmonary resuscitation (CPR) training for the lay public. This training should be short, easy to understand, and easy to remember. CPR courses should be readily available in every locale.

Several CPR training programs for the public include training in the use of automated external defibrillators (AEDs). Public access defibrillation, the use of AEDs by laypersons on victims of out-of-hospital cardiac arrest, has been endorsed by members of the medical profession and advocacy groups. ACEP strongly recommends that communities which implement public access defibrillation programs ensure that such programs are integrated and coordinated with existing emergency medical service (EMS) systems as follows:

EMS systems must be notified of the location of AEDs at the time they are deployed. Each use of an AED by a layperson should be accompanied by simultaneous activation of the EMS system to ensure timely provision of advanced life support and transport to an emergency medical facility. Standards for appropriate training, equipment maintenance, and ongoing monitoring of quality of care and outcomes must be established in conjunction with local medical control authorities. Legislation should provide liability protection for all parties involved in the use of an AED by a laypersonincluding the individual who uses the AED, the entity that purchases or provides the AED, the entity that provides training for the use of the AED, and the medical professionals providing oversight to the layperson. ACEP endorses the support of further research to determine the effectiveness of public access to AEDs used by laypersons.

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American College of Emergency Physicians

The American College of Emergency Physicians (ACEP) believes that the efficacy of early defibrillation with the reliable technology of current automatic external defibrillators (AEDs) is proven and widely accepted within the out-of-hospital provider community. However, before early defibrillation programs can be promoted in a widespread manner, they must be integrated into or coordinated with EMS systems that are designed to maximize the potential for survival in the ventricular fibrillation victim.

AEDs should be carried by all basic life support ambulances. AEDs should also be available to Medical First Responders such as police and fire personnel and to other designated first responders in highly congested population areas.

ACEP endorses the widespread availability of AEDs and the implementation of early defibrillation programs coordinated with an EMS delivery system to ensure the following:

  • Immediate activation of the EMS system for the ventricular fibrillation victim
  • Immediate delivery of CPR
  • Early defibrillation by the first designated responder to arrive on the scene
  • Timely provision of advanced life support
  • Rapid transport to an emergency medical facility
  • Medical direction of all components including the AED program
  • All of these factors are critical to ensure that the EMS personnel can optimally treat victims of cardiac arrest. Appropriate monitoring of quality of care and outcomes must occur. Legislation may be necessary in some locations to allow for Medical First Responders to use AEDs.

Policy Number 400202
Approved by the ACEP Board of Directors, June 1999
www.acep.org

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American College of Occupational and Environmental Medicine Guidelines on Automated External Defibrillation

Introduction

On November 13, 2000, President Clinton signed into law H.R. 2498, the Cardiac Arrest Survival Act (CASA), designed to expand the availability of automated external defibrillators (AEDs) in public settings. The new legislation requires the Secretary of the Department of Health and Human Services (HHS) to establish guidelines for the placement of AEDs in buildings owned or leased by the federal government.

The American College of Occupational and Environmental Medicine (ACOEM), while applauding this legislation urges the consideration of AEDs in selected workplaces, beyond the scope of federal buildings. The College has thus developed this guideline to increase the awareness of the value of AEDs and has presented recommendations to encourage and provide guidance on their use in the workplace. This guideline reviews the following topics: (1) epidemiology, morbidity, and mortality of cardiovascular diseases in the workplace; (2) the “chain of survival” paradigm; (3) history and descriptions of AEDs; (4) standard-of-care interventions and guidelines; (5) public-access defibrillation and federal initiatives; and (6) recommendations for establishing and managing a workplace AED program.

Epidemiology, Morbidity and Mortality

Heart disease is a significant public health concern. The American Heart Association estimates that in 1997 alone, 7,700,000 Americans experienced myocardial infarctions and 6,300,000 suffered from angina pectoris.1

During 1996, reported incidence rates in the United States for the combination of ischemic heart disease and heart rhythm disorders, including tachycardia and other unspecified rhythm disorders, were 78.1 per 1000 persons.2 Among working-age adults, incidence rates were 39.3 per 1000 persons for those 18-44 years, and 116.4 per 1000 persons for those 45-64 years.3

The Occupational Safety and Health Administration reported that from 1991-1993, 15% of workplace deaths were due to sudden cardiac arrest (SCA)4 Data collected from Calgary, Alberta, from 1992-1996, revealed that 13% of cardiac arrest deaths occurred in public or commercial sites, 5% were in large buildings (> 250 people), and 8% in small buildings (< 250 people).5 Data reported from a 1990-1994 Seattle area retrospective cohort study found 16% of cardiac arrests occurred in public places.6

SCA and the Chain of Survival

There are several electrical abnormalities that result in SCA, but the majority of deaths begin with an initial rhythm of ventricular fibrillation (VF).7-9 If VF is not treated quickly, this potentially reversible dysrhythmia typically degenerates into asystole, which is generally fatal.10 The standard medical protocol to correct VF and pulseless ventricular tachycardia (VT) is the application of electric shock with a controlled dose and duration of energy. If the initial shocks fail to convert the rhythm, advanced cardiac life support (ACLS) protocols call for a series of medications to be given in a medication-shock, medication-shock sequence.

Factors contributing to out-of-hospital survival following SCA have been described primarily in terms of the time-related “chain of survival” paradigm.11 The four links of the chain include: (1) early recognition and call for emergency medical services; (2) initiation of basic life support CPR; (3) defibrillation; and (4) advanced cardiac life support (ACLS) drug intervention. Survival depends on the availability of the links – although more advanced applications may jump ahead of lesser ones. For example, if community emergency medical service (EMS) responders – or medical providers at the scene – are not qualified or prepared to deliver ACLS, this link may not be available until the patient arrives at a medical center. If a workplace has basic life support providers equipped with an AED and an ACLS-level medical department, the timing between these links may be shorter.

Without intervention, survival following SCA decreases rapidly. Several studies have reported that for each minute of untreated cardiac arrest, the probability of successful rhythm conversion decreases by 7% to 10%, producing an equivalent per-minute-death rate.12,13 Conversely, survival rates as high as 90% have been reported when the collapse-to-defibrillation time is within one minute.14-16 To better define each the contribution of each link in the “chain of survival,” data were examined between 1976 and 1991 in Seattle.17 A best fit model demonstrated a fit with the following equation:

Survival rate = 67% at collapse – 2.3% per minute to CPR – 1.1% per minute to defibrillation – 2.1% per minute to ACLS

As noted by the authors:

“The regression constant, 67%, represents the probability of survival in the hypothetical situation in which all treatments are delivered immediately on collapse to patients with prehospital cardiac arrest … With delays in CPR, defibrillatory shock, and definitive care, the magnitude of the decline in survival rate per minute is the sum of the three coefficients (-2.2%, -1.1%, -2.1%), or –5.5%.”17

It is clear that while some variation in the time/survival equation exists, the sooner VF is treated, the more likely a positive outcome. Moreover, data show that some adults in VF remain neurologically intact even when defibrillation is delayed for up to 10 minutes after arrest if CPR is provided. 14,18,19 Indeed, performing CPR prior to defibrillation seems to prolong VF, which may “buy time” until an AED can convert the rhythm, thereby helping to preserve heart and brain function.17,20 CPR without electric therapy may sustain a patient in VF for a short time but only rarely restores an organized rhythm. As return of an adequate perfusing rhythm requires immediate application of the combination of CPR, defibrillation, and ACLS within a few minutes of arrest, establishing controls to permit smooth and fast support of the chain of survival enhances the probability of survival.

History and Descriptions of AED

While conventional, manual external defibrillators have been used in clinical settings and some emergency medical services (EMS) for nearly 50 years, the automated external defibrillator (AED) did not make its debut until 1979.21 Utilizing solid-state circuitry and micro-computer technologies, the modern AED identifies VF, voice prompts a user to prepare to deliver a shock, and when a button is pushed, delivers the electric charge. Many studies have shown that AEDs are nearly error-free22 and effective when used by hospital-wide resuscitation teams,23 EMTs,24-26 fire department rescuers,23 police officers,27,28 and non-medical, first-aid responders in the workplace.29-31 In the last decade, there has been a remarkable increase in the placement and use of AEDs. Reasons include the accumulation of additional clinical studies confirming the safety, efficacy, and accuracy of these devices;32-34 the development of a smaller and lighter batteries and cases (less than 5 lbs); and the easy-to-follow audio prompt instructions.

Types of AEDs

The term “AED” commonly refers to any device that analyzes cardiac rhythm and prompts a user to deliver a shock when necessary. These devices only require a user to attach pads to a patient’s chest, turn the device on, and follow audio instructions. They do not require any decision-making or interpretation of symptoms. Most AEDs, therefore, are “automated” in that they analyze and advise. “Fully automated” or “automatic” external defibrillators that deliver a shock without a prompt to press a shock button are available for special situations.

Analysis of Rhythms

AEDs utilize microprocessors to analyze several characteristics of the surface ECG signal. Wave frequency, amplitude, and some integrated features such as slope or morphology are identified and compared to preset values. In an unresponsive, non-breathing, pulseless patient, an AED will advise shocks for monomorphic and polymorphic ventricular tachycardia (VT), supraventricular tachycardia (SVT), or VF. When shock advisories have been reported for patients with perfusing ventricular or supraventricular arrhythmias,35 these were confirmed as due to interpretation, reporting and response errors of operators not device, errors.36

Device “Errors”

An AED should be used for management of full cardiac arrest, and only when all movement is absent. Any patient movement (e.g., patient transport, seizures, or agonal respirations) can disrupt the ability of the device to complete rhythm analysis. Occasional errors have also been reported due to failure to deliver shocks in cases of extremely fine or course VF, 37 incomplete cycles of analysis,24,31 failure to follow the AED manufacturer’s instructions, 34 and conflicts with an implanted defibrillator.38

Waveforms and Energy Levels

Although there is no clear relationship between adult body size and energy requirements, the dose and duration of AED energy must be appropriate. When energy or current is too high, there is a risk of cardiac injury and myocardial infarction; when too low, the shock may fail to terminate VF or other arrhythmias.39-41

Modern AEDs provide one of two categories of waveforms: monophasic or biphasic. Monophasic waveforms provide current flows in a single direction (polarity). When the rate at which the pulse falls to zero is gradual, they are referred to as monophasic damped sinusoidal (MDS). When the rate is instantaneous, they are called monophasic truncated exponential (MTE). Biphasic waveform defibrillators deliver a sequence of two pulses in which the second is of opposite polarity to the first. While biphasic damped sinusoidal (BDS) and biphasic truncated exponential (BTE) are both technically possible, current manufacturers only market BTE devices. To maximize the success of the shock, monophasic AEDs use an escalating energy sequence. The recommended energy for the first shock is 200 J, followed by 200 J to 300 J in the second, and 360 J in the third.42 Studies have shown that BTE low shocks energy (200 J or less) are equal or superior to 200 J MTE shocks in terminating short duration VT and VF, and produce fewer ST segment changes.43,44, 45

Public Access Defibrillation and Federal Initiatives

The concept of public access defibrillation (PAD) gained momentum when the American Heart Association Task Force on the Future of CPR challenged the medical device industry to create AEDs that would make early defibrillation accessible to the public.46 The rationale for PAD was based on the concern that in many densely populated areas, traditional EMS responders cannot respond in sufficiently short time to perform resuscitation and maximize survival. It was determined that the training and equipping of non-traditional (non-EMS) responders to use AEDs and provide resuscitation until arrival of EMS was a practical and appropriate solution to that problem.

To date, 48 states have passed legislation describing the process of acquisition and use of an AED by lay responders. Since the Food and Drug Administration regulates AEDs as prescription devices, acquisition requires medical involvement. However, details of such requirements for medical involvement vary across states. Elements commonly addressed in state legislation include immunity for rescuers, acquirers, and enablers; training requirements for users; medical supervision or involvement; and EMS notification.

Supporting PAD are three federal initiatives:

  • The aforementioned Cardiac Arrest Survival Act (CASA) which instructs the Secretary of Health and Human Services to make recommendations to promote public access to defibrillation programs in federal and other public buildings. The Act also extends Good Samaritan protections to AED users and the acquirers of the devices in any states without such immunities.
  • “Guidelines for Public Access Defibrillation in Federal Facilities”47 issued by the Department of Health and Human Services (HHS) and General Services Administration (GSA) to “provide a general framework to initiate a design process for a public access defibrillation (PAD) program in federal facilities.”
  • Finally, on April 21, 2001, the Department of Transportation, Federal Aviation Administration issued “Emergency Medical Equipment; Final Rule”48 which requires an AED and other associated first-aid supplies for all passenger-carrying aircraft with at least one flight attendant.


Guidelines for the Use of Automated External Defibrillators (AEDs) in Workplace Settings

The American College of Occupational and Environmental Medicine (ACOEM) supports the establishment of programs by employers to use automated external defibrillators (AEDs) to manage sudden cardiac arrest in workplace settings. In establishing a workplace AED program, it is important to obtain support for the program from the organization’s leadership, including agreement about the goals, implementation requirements and costs of the program.

ACOEM recommends that employer-sponsored programs for the use of AEDs in
workplaces and public settings, include all of the following elements:


1.Establishment of a centralized management system for the AED program It is recommended that a centralized management system be established for the workplace AED program within each organization. It is important that clear lines of responsibility be established for the program, and that roles are defined for those who oversee and monitor the program.

2. Medical direction and control of the workplace AED program
It is recommended that all workplace AED programs be under the direction and
control of an appropriately qualified physician. It is recommended that all workplace AED programs be medically supervised by an appropriately qualified physician or health care provider licensed for independent practice and be in compliance with medical control requirements of the administrative code of the state where the AED is provided. It is recommended that the responsibilities of the program medical director include helping to develop and/or approving medical aspects of the program. Specific areas where medical direction is important include providing the written authorization required in most locations to acquire an AED, ensuring provisions are made for appropriate initial and continued AED training, and performing a case-by-case review each time an AED is used at the site. It is recommended that additional responsibilities include establishing or integrating the AED program with a quality control system, compliance with regulatory requirements (see recommendation #3) and ensuring proper interface with EMS. It is recommended that administrative coordination of workplace AED programs be provided by a licensed health care professional or an appropriately qualified health or safety professional responsible for workplace emergency programs. It is recommended that the day-to-day management of the AED program be supervised by the administrative coordinator in consultation with the program medical director for issues of medical control.

3. Awareness of and compliance with federal and state regulations It is important that both the AED program medical director and management responsible for the worksite AED program identify and comply with relevant state legislation49 on public access defibrillation (PAD) and the federal Cardiac Arrest Survival Act.50 These regulations may impose specific requirements that vary from state to state; therefore, a single corporate policy may be insufficient unless it meets the most stringent requirements imposed by all jurisdictions where a workplace AED program is in place. As federal and state AED legislation requires that every person expected to use an AED be properly trained, it is recommended that training be recognized and standardized. Course content must include CPR, use of the AED, and should be integrated with other first aid responder programs at the workplace. It is recommended that CPR and AED skills review and practice be conducted at least annually, and encouraged semi-annually.51

4. Development of written AED program description for each location It is recommended that a written document describing the workplace AED program be prepared for each location where an AED will be placed. It is recommended that such a written document address all of the 12 recommended program elements stated in this guideline.

5. Coordination with local emergency medical services As is required by many state PAD regulations, it is important that information about each workplace AED program be communicated to community emergency medical services (EMS) providers and coordinated with EMS response protocols.

6. Integration with an overall emergency response plan for the worksite It is recommended that the workplace AED program should be a component of a more general medical emergency response plan, rather than a freestanding program. It is important that the emergency medical response plan describe in sufficient detail the continuum of personnel, equipment, information, and site activities associated with managing the range of anticipated occupational injuries and illnesses for a patient who is breathing or in sudden cardiac arrest. It is recommended that all employees be informed about the medical emergency response plan including the proper means for notifying trained internal and community emergency responders in the event of a suspected cardiac arrest, or other medical emergency. It is recommended that, when a workplace AED program is in place, the part of the workplace medical emergency response plan dealing with suspected cardiac events included specific recommendations about the following:

  1. Notification of workplace medical personnel and first aid  responders during all operating times of the site;
  2. Assessment of the situation by the first trained responders at the scene;
  3. Notification of the community emergency medical service  (EMS) system;
  4. Appropriate first aid including body substance isolation procedures and use of CPR and AEDs by first aid responders if indicated;
  5. Clinically appropriate patient transport from workplace to medical facility, including how appropriate continuation of care will be ensured;
  6. Responder debriefing and equipment replacement;
  7. Methods to review the follow-up care received by the patient.

7. Selection and technical consideration of AEDsIt is recommended that selection of AED equipment be based on the most current recommendations of the American Heart Association (AHA), available in Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.51 These AHA guidelines state that compared to higher-energy escalating (200 J, 300 J, 360 J) monophasic-waveform defibrillators, relatively low energy level (= 200 J) biphasic waveform defibrillation devices have been shown to be “safe and of equivalent or higher efficacy for termination of VF.”51 It is also recommended that if a higher-energy escalating monophasic defibrillator has been previously acquired, it may be utilized so long as training of responders adequately addresses particular aspects of such devices.

8. Ancillary medical equipment and supplies for the workplace AED program In addition to the AED, other medical equipment and supplies are required to support the safe and complete management of workplace cardiac emergencies. Therefore, it is recommended that the following supplies be provided in addition to the defibrillator as part the AED program:

  1. Bloodborne pathogens responder and clean-up kits52 to ensure compliance with body substance isolation procedures
  2. CPR barrier masks with oxygen port to permit delivery of supplemental oxygen51
  3. AED responder kits to support electrode pad connections. Items include a razor (to shave chest hair) and towel (to dry sweat from the chest or after removal of a nitroglycerine transdermal patch);53
  4. Appropriate portable emergency oxygen equipment51,54 to increase oxygen during resuscitation and to support inhalation following restoration of breathing;
  5. CPR audio prompting device51 to guide action and timing sequences of CPR ventilations and compressions.

9. Assessment of the proper number and placement of AEDs and supplies It is recommended that when practical, AEDs be placed in locations throughout a workplace that will allow initiation of resuscitation and use of the AEDs (the “drop-to-shock” interval) within 5 minutes of recognized cardiac arrest. Estimating time needed for transport and set up the AED for various work areas can help determine if a proposed location for AED placement is appropriate.

10. Scheduled maintenance and replacement of AED and ancillary equipment It is important that AEDs be maintained in optimal working condition. It is recommended that, at a minimum, the AED manufacturer’s recommended service schedule be followed, and that records of all servicing and testing be maintained. It is also recommended that any workplace AED program ancillary medical equipment and supplies (e.g., emergency oxygen) used be maintained as recommended by the manufacturers or suppliers. It is recommended that all emergency equipment be evaluated, serviced, or replaced as necessary following use. It is recommended that records be maintained of the dates and details of servicing or replacement of AEDs or ancillary equipment and supplies used.

11. Establishment of an AED quality assurance program - It is recommended that an AED quality assurance program be established that includes at least the following components:

  1. Medical Review - A case-by-case review for every use of each AED to treat a human by an appropriately qualified physician. (See also the recommendation above on “Medical Direction and Control.”)
  2. Record keeping:
    1. Records of all AED-related training including names of instructors,  workplace personnel trained, courses completed, and dates of initial, review, renewal, or skill practice classes;
    2. Records of all AED locations, service and updates;
    3. Records of medical reviews of AED implementation.
  3. Program evaluation - Standardized methods to assess the efficacy of the program, and a system to remediate or improve components as necessary.

12. Periodic review and modification of the Workplace AED program protocols.  It is recommended that all components of the workplace AED program be  reviewed at least annually and modified as appropriate. As personnel or work  practices evolve, there may be need to change the location, means of access, or procedures used to implement AEDs in the workplace.

Summary

ACOEM supports ongoing efforts to enhance emergency response to medical emergencies in the occupational environment. Development of programs to utilize AEDs is a reasonable and appropriate aspect of such programs to manage sudden cardiac arrest, an important cause of morbidity and mortality among working age adults. Implementation of such an AED program, which should be a component of a more general worksite emergency response plan, requires clearly defined medical direction and medical control.

Acknowledgements

This ACOEM guideline was prepared by Larry M. Starr, PhD, under the auspices of the Council on Scientific Affairs. It was peer-reviewed by the members of the Council and approved by the ACOEM Board of Directors on February 11, 2001.

The guideline was reaffirmed in its entirety by the ACOEM Board of Directors on May 6, 2006.

http://www.acoem.org

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American Heart Association

"It is essential to integrate the concept of early defibrillation into an effective emergency cardiac care system. This is best characterized by the "Chain of Survival" concept, which includes early access to the emergency medical services system, early cardiopulmonary resuscitation when needed, early defibrillation when indicated, and early advanced care. To achieve the goal of early defibrillation, the American Heart Association endorses the position that all emergency personnel should be trained and permitted to operate an appropriately maintained defibrillator, if their professional activities require that they respond to persons experiencing cardiac arrest. This includes all first responding emergency personnel, both hospital and non-hospital (e.g., non-EMT first responders, firefighters, volunteer emergency personnel, emergency medical technicians, paramedics, nurses and physicians). To further facilitate early defibrillation, it is essential that a defibrillator be immediately available to emergency personnel responding to a cardiac arrest. Therefore all emergency ambulances and other emergency vehicles that respond to or transport cardiac patients should be equipped with a defibrillator." Circulation 1991;83(6):2233.

Public Access Defibrillation: A Statement for Healthcare Professionals From the American Heart Association Task Force on Automatic External Defibrillation

"Early bystander cardiopulmonary resuscitation (CPR) and rapid defibrillation are the two major contributors to survival of adult victims of sudden cardiac arrest. The AHA supports efforts to provide prompt defibrillation to victims of cardiac arrest. Automatic external defibrillation is one of the most promising methods for achieving rapid defibrillation. In public access defibrillation, the technology of defibrillation and training in its use are accessible to the community. The AHA believes that this is the next step in strengthening the Chain of Survival. Public access defibrillation will involve considerable societal change and will succeed only through the strong efforts of the AHA and others with a commitment to improving emergency cardiac care.

Public access defibrillation will include:

  • Performance of defibrillation by laypersons at home and by firefighters, police, security personnel, and nonphysician care providers in the community
  • Exploration of the use of bystander-initiated automatic external defibrillation in rural communities and congested urban areas where resuscitation strategies have had little success.

The AHA can also play a major role by:

  • Increasing public awareness that defibrillation improves the rate of survival from an often fatal condition that each day affects 1,000 Americans
  • Ensuring that objective, current research data are used to guide implementation of these changes in performance and teaching of CPR
  • Working with medical manufacturers, legislators, and governmental agencies to promote safety and efficacy, reduce cost, and update training requirements to facilitate implementation of public access defibrillation. Broader use of automatic external defibrillators should also lead to readiness tests and
    features that deter both misuse and misapplication. Meaningful change will occur only with the broad public support that has traditionally characterized the AHA's efforts in the fight against heart disease and stroke."

Circulation 1995;92:2763.

Defibrillation Scientific Position
Low Energy Biphasic Waveform Defibrillation:
Public Access Defibrillation
Report on 1994 Public Access Defibrillation Conference
Automatic External Defibrillators for Public Access Defibrillation: Recommendations for Specifying and Reporting Arrhythmia Analysis Algorithm Performance, Incorporating New Waveforms, and Enhancing Safety
Automated External Defibrillators: Time for Federal and State Advocacy and Broader Utilization American Public Health Association, Injury Control Section Recommendations for Healthy People 2010


"By 2010, all prehospital EMS personnel will be trained in the use of the automatic external defibrillator. Rationale: Most EMS personnel now have AEDs in their training, but many, especially "first responders" do not. In order to reach peak public health efficacy, AEDs need to be available, with people who know how to use them, within four minutes response time to cardiac arrest victims."

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The American Red Cross

"The American Red Cross supports legislation and other government action at the local, state and federal levels to encourage mandatory training in Automatic External Defibrillation (AED) for individuals who have legal responsibility to provide emergency care, including fire fighters, police, emergency medical personnel and lifeguards. AED is an automatic device used to recognize a fatal heart rhythm that requires a shock and either delivers the shock or prompts the rescuer to deliver. In addition, the American Red Cross supports the expansion of AED training to the general public for people that may have a need--such as individuals who have family members with cardiac problems. The Red Cross supports legislation to ensure access to emergency medical services and that AEDs should be available at public access sites such as office buildings, stadiums, arenas, and other sites where large numbers of the public gather." December 1997.

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Canadian Association of Emergency Physicians Public Access Defibrillation Working Group

"Out-of-hospital sudden cardiac arrest, caused by ventricular fibrillation, is a leading cause of death in Canada. The most effective treatment available to out-of-hospital victims of sudden cardiac arrest is early defibrillation. Experience has shown that targeted responders (e.g., police, security personnel, flight attendants) can learn to use an automated external defibrillator (AED) safely and effectively. The Canadian Association of Emergency Physicians (CAEP) believes that Public Access Defibrillation (PAD) programs, through targeted responders using AEDs, have the potential to improve survival from out-of-hospital cardiac arrest."

CAEP also believes that:

  • Scientific research and physician direction are required to determine the safety, success and cost-effectiveness of targeted responder PAD programs, and of PAD programs where lay responders function in less structured settings;
  • Provincial regulations or legislation should ensure immunity from civil liability for: a PAD responder who renders emergency care through the use of an AED (for any personal injury as a result of such care, or failure to provide such care), an entity that provides training of PAD responders, a physician who provides medical direction for a PAD program, a person or entity who purchases and deploys an AED for a PAD program, provided that the personal injury does not result from individual or PAD program gross negligence or willful or wanton misconduct;
  • PAD programs should meet or exceed existing guidelines, developed by recognized provincial or national emergency cardiac care organizations, for AED and CPR training and skill maintenance;
  • PAD programs should be coordinated with local, regional or provincial emergency medical services (EMS) authorities to ensure: compatible patient transfer-of-care protocols, that community AEDs are registered with the EMS authority, a written, on-site emergency response protocol to rapidly activate the PAD responder and early 911 notification in the event of a cardiac arrest;
  • Physician direction is required to oversee development and authorization of the following PAD program elements: patient treatment protocols, PAD responder training and skill maintenance, collection, storage and transfer of clinical data to the EMS authority to allow for continuous surveillance of community cardiac arrest management and outcomes, a quality assurance program to review each case where an AED is applied to a patient; a plan for continual AED readiness-for-use and maintenance must be in place according to the AED manufacturer's operational guidelines;
  • The principle of continuity of EMS patient care must be maintained to ensure that once 911 is called, every patient treated under a PAD program becomes the responsibility of EMS personnel, the EMS system and the EMS system's medical directors.

Definitions:

  • Targeted responder: A person trained in AED use, under a PAD program, who normally has a duty to respond to and perform CPR on a victim of out-of-hospital cardiac arrest. (e.g., police, security guards, flights attendants, lifeguards, first aid officers)
  • Lay responder: A person trained in AED use, under a PAD program, who does not normally have a duty to respond to and perform CPR on a victim of out-of-hospital cardiac arrest (e.g., store clerks, ushers, secretarial staff, janitorial staff, personal care attendants)

October 2001
www.caep.ca

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Citizen CPR Foundation

"The Citizen CPR Foundation urges all communities to implement and monitor effective emergency cardiac care systems that address each link in the Chain of Survival. This includes early defibrillation capabilities to ensure that personnel trained in CPR and capable of providing defibrillation can arrive at the victim's side within minutes of cardiac arrest." (Excerpt.)

Currents in Emergency Cardiac Care 1993;4(4).
www.citizencpr.org

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Emergency Care Research Institute

"The American Heart Association recommends that response times to a cardiac arrest average no more than two minutes in a specific hospital location. However, in most hospitals, extensively trained, specially designated resuscitation or code teams respond to cardiac arrest using conventional manual defibrillators. Although response times in hospitals often are perceived as being short, studies have shown that in some hospitals, delays greater than five minutes can occur before in-hospital response teams deliver the first shock. According to ECRI, dissemination of AEDs in multiple locations throughout the hospital and training in their use by additional hospital personnel could reduce response times and increase survival rates."

"AEDs may be particularly advantageous in settings where delays in response times are likely to occur. These include noncritical areas and outpatient and diagnostic facilities where staff are not trained to respond to cardiac emergencies. With two hours training, noncritical care nurses can learn and retain the knowledge and skills necessary to use AEDs."

"The American Heart Association recommends that response times to a cardiac arrest average no more than two minutes in a specific hospital location. However, in most hospitals, extensively trained, specially designated resuscitation or code teams respond to cardiac arrest using conventional manual defibrillators. Although response times in hospitals often are perceived as being short, studies have shown that in some hospitals, delays greater than five minutes can occur before in-hospital response teams deliver the first shock. According to ECRI, dissemination of AEDs in multiple locations throughout the hospital and training in their use by additional hospital personnel could reduce response times and increase survival rates." "AEDs may be particularly advantageous in settings where delays in response times are likely to occur. These include noncritical areas and outpatient and diagnostic facilities where staff are not trained to respond to cardiac emergencies. With two hours training, noncritical care nurses can learn and retain the knowledge and skills necessary to use AEDs."

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Emergency Care Research Institute/ Healthcare Risk Control

“Healthcare facilities should maintain AEDs in parts of their own facilities where cardiac teams may have difficulty reaching patients quickly, such as in outpatient clinics or physically remote parts of the building. Organizations should also ensure that physicians and staff are educated about other aspects of the new guidelines and that the guidelines are incorporated into CPR training programs.”

More information can be found here.

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Heart & Stroke Foundation of Canada ECC Coalition Task Force

"The health care system has the responsibility to ensure early defibrillation (8 to 10 minutes from collapse) as an accepted standard of care and that appropriate resources should be available to permit early defibrillation for all."

Heart and Stroke Foundation of Canada "Public Access to Defibrillation: A Statement from the AED Taskforce

The Heart and Stroke Foundation of Canada recommends that:

  • Early defibrillation initiatives be implemented within the community Chain of Survival;
  • Targeted responders be authorized, trained, equipped and directed to operate an AED
    if their responsibilities require them to respond to persons in cardiac arrest;
  • The implementation of an AED program must be linked with the emergency medical services system and implemented within systems which provide medical oversight, training, quality assurance, data collection and evaluation;
  • Hospitals are encouraged to examine their policies and procedures for cardiac arrest and resuscitation to determine if utilization of AEDs within the hospital setting could reduce time to defibrillation;
  • In settings where professionals trained in advanced life support are not immediately available, AED training should be provided as a basic skill for designated healthcare providers;
  • Family members or companions of individuals at high risk for a cardiac event may choose to be trained to use AEDs under the direction of a physician.

At this time, efforts should be directed to strengthening the Chain of Survival and ensuring access to AEDs by targeted responders in all Canadian communities. In the future, efforts to expand the use of AEDs by bystanders may be warranted."

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International Association of Chiefs of Police and International Association of Fire Chiefs

"Whereas, medical experts have determined that the sooner a heart attack* victim can be defibrillated, the greater chance the victim will survive; and

Whereas, police officers are often the first emergency personnel to arrive on the scene of a heart attack* victim; and

Whereas the medical industry has developed automated external defibrillators that can allow non-medical personnel to safely and effectively defibrillate heart attack* victims; and

Whereas the use of automatic external defibrillators by police officers could result in the saving of countless; and

Whereas the American Heart Association has endorsed the concept of equipping police offers and other public safety first response personnel with automatic external defibrillators; and

Whereas both the International Association of Chiefs of Police and the International Association of Fire Chiefs are organizations dedicated to ensuring that both police and fire-fighting agencies have the equipment necessary to protect and assist the public; now, therefore be it

Resolved, that the leaders of the International Association of Chiefs of Police and the International Association of Fire Chiefs work together to promote the used of automatic external defibrillators by police and firefighters.

1997
www.theiacp.org
www.iafc.org

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International Association of Fire Fighters

"It would be medically optimal if every community in North America were covered by fire fighter first responders who are trained and equipped to defibrillate and who arrive in less than five minutes."

www.iaff.org

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International Liaison Committee on Resuscitation

"To achieve the earliest possible defibrillation, the International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings nonmedical individuals should be allowed and encouraged to use defibrillators. ILCOR recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first-responding emergency personnel, in both the hospital and out-of-hospital settings, whether physicians, nurse or nonmedical ambulance personnel. The widespread availability of automated external defibrillators (AEDs) provides the technological capacity for early defibrillation by both ambulance crews and lay responders." Circulation 1997;95:2183-2184.

www.americanheart.org/scientific/statements/1997/049706.html

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National Association of EMS Physicians

"Sudden cardiac death is a major public health problem, claiming as many as 350,000 lives each year in the United States. Many who suffer sudden cardiac arrest can be successfully resuscitated if certain critical actions such as 9-1-1 access, bystander cardiopulmonary resuscitation, rapid defibrillation and prehospital advanced life support, are accomplished in a timely and effective manner. Since rapid defibrillation is the most critical of these interventions, strategies to enhance survival should focus on reducing the interval from collapse to defibrillation.

The development of the automated external defibrillator (AED) has made it feasible to train and equip basic level emergency responders with defibrillators and thus make early defibrillation more readily achievable. Available data indicate that AEDs can generally be effective when used by traditional (EMS & fire service) and some non-traditional (police, security, or flight attendant), first responders.

Increased survival has been postulated if other non-traditional first responders (building managers or health club employees, for example) and minimally trained or untrained bystanders have access to AEDs. The use of AEDs by this group is a concept that holds promise, despite insufficient data to demonstrating effectiveness or safety. One important concern is that providing these groups with access to AEDs could result in potential delays in activation of the EMS system that may be detrimental to patient outcome.

The Vision of NAEMSP is that all victims of sudden cardiac arrest should have rapid defibrillation available. Each community must perform a needs assessment and make appropriate resource allocations to identify optimal AED deployment strategies. To explore the role of nontraditional AED providers, NAEMSP strongly encourages continuing scientific studies of the effectiveness, safety and costs of AED programs. To enable cost-effective and appropriate public health policy decisions, cardiac arrest should be subject to the same epidemiologic scrutiny as are other reportable public health events.

Making AEDs available to non-traditional responders or minimally trained or untrained bystanders may be an effective strategy for achieving early defibrillation in certain communities. Regardless of the deployment strategy, there must be strong medical direction for each AED program and each community must also assure these AED programs are integrated into the local EMS system and included in quality assurance activities. Integration of AED programs into existing EMS systems is essential to ensure there are minimal delays in activating and transitioning care to the EMS system. State and federal governments must support persons who do not have a 'duty to respond' by developing or revising Good Samaritan laws to protect them from liability for good faith use of AEDs."

Approved by the NAEMSP Board of Directors, January 2000.

http://www.naemsp.org/Position%20Papers/EarlyDefib12000.html

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National Association of EMS Physicians


“The Use of Automated External Defibrillators in Children:

  1. Although the incidence of ventricular fibrillation (VF) in children is far less than that of adults, the outcome for VF is better than for other nonperfusing rhythms and is improved with early defibrillation.

  2. Strategies for the treatment of pediatric arrest should focus on shortening the intervals from collapse to recognition of VF and to defibrillation.

  3. Data on the correct emergency for defibrillation of children are limited. Animal studies suggest that the immature heart is less susceptible to energy-related damage than the adult heart and that there is a wide therapeutic range of defibrillation energy dose.

  4. Although using a fixed energy automated external defibrillator (AED) in some children may have the potential for harm, not treating VF has the potential for even greater harm, death of the child. As such, defibrillation should not be withheld based on weight and size criteria alone.

  5. Systems should attempt to provide defibrillation to children suffering VF in the timeliest fashion possible. Strategies may include:

    • Manual defibrillation
    • AEDs designed for defibrillation of young children
    • Standard AEDs used in children with appropriate protocols and medical oversight.”

Published in Prehospital Emergency Care, April/June 2003

http://www.naemsp.org/pdf/Defibrillators.pdf

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National Center for Early Defibrillation

Click on the following to download PDF:

National Center for Early Defibrillation

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The National Association of State Emergency Medical Services Directors

"Sudden cardiac arrest is a major public health problem that ultimately must be addressed in individual communities and states through a data driven needs assessment and appropriate resource allocation...NAEMSD pledges to work cooperatively with other national organizations such as the American Heart Association and American Red Cross, to ensure that all our citizens have access to early defibrillation programs that are effective and safe."

http://www.naemsd.org/1997_positions.html

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National Council of State EMS Training Coordinators, Inc.

"...Whereas the National Council of State EMS Training Coordinators, Inc., is a major player in the "chain of survival" and promotes the training of EMS providers in early defibrillation, now therefore be it resolved, that the National Council of State EMS Training Coordinators, Inc., urges the American Heart Association and its affiliates and state EMS offices to work together in addressing concerns with the AHA proposed implementation plans for public access defibrillation within states."

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National Fire Protection Association (NFPA) 1710 Standards

Excerpts:

“Emergency medical services must be deployed within four or fewer minutes response time (the time that begins when units are en route to the emergency incident and ends when units arrive at the scene). First Responders (are responsible for) functional provision of initial assessment, i.e., airway, breathing, and circulatory systems, and basic first-aid intervention, including CPR and automatic external defibrillator capability, with Automatic External Defibrillators (AEDs)…

Basic Life Support (BLS) responders, four or fewer minutes response time, (are responsible for) functional provision of patient assessment, including basic airway management; oxygen therapy; stabilization of spinal, musculo-skeletal, soft tissue, and shock injuries; stabilization of bleeding; and stabilization and intervention for sudden illness, poisoning and heat/cold injuries, childbirth, CPR, and Automatic External Defibrillator (AED) capability…

Advanced Life Support (ALS), eight or fewer minutes response time, (are responsible for) functional provision of advanced airway management, including intubation, advanced cardiac monitoring, manual defibrillation, establishment and maintenance of intravenous access, and drug therapy.”

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National Heart, Lung and Blood Institute

"Early defibrillation of cardiac arrest victims is essential. The earlier the victim is defibrillated, the greater the chance of survival. Automated external defibrillators now make it possible for basic level emergency medical technicians and first responders-as well as paramedics-to defibrillate reliably and safely. Consequently, all EMS personnel, including first responders, should be trained to operate AEDs and all emergency medical vehicles should be equipped with defibrillators (manual or AEDs)." National Heart Attack Alert Program, Staffing and Equipping EMS systems: Rapid identification and treatment of acute myocardial infarction, NIH Publication No. 93-3304, 1993.

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The following position statement advised caution.
 

American Association of Occupational Health Nurses (AAOHN)

"RATIONALE Since the introduction of cardiopulmonary resuscitation more than 35 years ago, few improvements have resulted in significantly improved outcomes other than the advent of early defibrillation (Weil & Tang, 1997). New defibrillation devices have been developed which allow the device to sense the need for defibrillation. These devices, sometimes called "smart defibrillators" or automatic external defibrillators (AEDs), are beginning to be utilized by emergency services providers and also in limited occupational settings. A number of airlines have incorporated the use of AEDs in wide-body airplanes for long flights, where access to sophisticated medical services is difficult. Legislation mandating that aircraft be equipped with at least one piece of lifesaving equipment (such as an AED) for use in responding to a cardiac emergency has also been introduced in Congress. Clearly, as AED use becomes more widespread, implications for the occupational health setting will be evident.

Early access defibrillation must be combined with other elements of the American Heart Association's "Chain of Survival"-early access, early CPR, and early access to Advanced Cardiac Life Support (ACLS). In cities where CPR training is widespread and EMS response is rapid, the survival rate increased from nine percent to 30 percent when AEDs were available to first responders (American Heart Association, 1998). Although geared toward emergency medical services delivery systems, AAOHN recognizes the American College of Emergency Physicians' guidelines for early defibrillation programs as a beginning framework for the necessary components of an effective AED program. These components include designation of AED providers, an education program, a program coordinator, and a quality improvement program (American College of Emergency Physicians, 1992). However, any workplace AED program should include an on-site designated program coordinator. One important function of the program coordinator is to ensure that the devices are in working order. AAOHN believes that the occupational health nurse provides the continuity necessary for the provision of an effective and efficient occupational health and safety program. In this same regard, the occupational health nurse is the ideal candidate to manage a worksite AED program.

Because of the life-saving potential of these devices, a number of forces are ambitiously working to rapidly incorporate these devices in the occupational setting. AAOHN is particularly concerned about the current lack of data on the necessary educational training requirements for responders utilizing AEDs. In addition, more research is needed on the efficacy of these devices. Policy issues must also be addressed related to the use of these devices. Enabling legislation to allow first responders to be able to use these devices must occur at the state level. Good Samaritan laws need to be examined and or amended, if necessary, to ensure liability protections for volunteer users of the devices. Furthermore, FDA approval is still pending on many of these devices. For these reasons, AAOHN believes that more information and research is needed prior to widespread use of these devices at the worksite. At the very least, companies utilizing these devices need to have an AED program in place, which includes a designated program coordinator, an education program to train users of the devices, and a quality improvement program."

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Mission & Vision

The mission of the Sudden Cardiac Arrest (SCA) Foundation is to prevent death and disability from sudden cardiac arrest. The vision of the SCA Foundation is to increase awareness about sudden cardiac arrest and influence attitudinal and behavioral changes that will reduce mortality and morbidity from SCA.

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