AED use in businesses, public facilities and homes by minimally trained first responders

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

Characteristics and outcomes of AED use in pediatric cardiac arrest in public settings: The influence of neighborhood characteristics

BACKGROUND

Automated external defibrillators (AEDs) are critical in the chain of survival following out-of-hospital cardiac arrest (OHCA), yet few studies have reported on AED use and outcomes among pediatric OHCA. This study describes the association between bystander AED use, neighborhood characteristics and survival outcomes following public pediatric OHCA.

METHODS

Non-traumatic OHCAs among children less than18 years of age in a public setting between from January 1, 2013 through December 31, 2017 were identified in the CARES database. A neighborhood characteristic index was created from the addition of dichotomous values of 4 American Community Survey neighborhood characteristics at the Census tract level: median household income, percent high school graduates, percent unemployment, and percent African American. Multivariable logistic regression models assessed the association of OHCA characteristics, the neighborhood characteristic index and outcomes.

RESULTS

Of 971 pediatric OHCA, AEDs were used by bystanders in 10.3% of OHCAs. AEDs were used on 2.3% of children ≤1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p < 0.001). AED use was more common in neighborhoods with a median household income of >$50,000 per year (12.3%; p = 0.016), <10% unemployment (12.1%; p = 0.002), and >80% high school education (11.8%; p = 0.002). Greater survival to hospital discharge and neurologically favorable survival were among arrests with bystander AED use, varying by neighborhood characteristics.

CONCLUSIONS

Bystander AED use is uncommon in pediatric OHCA, particularly in high-risk neighborhoods, but improves survival. Further study is needed to understand disparities in AED use and outcomes.

Shocking the system: AEDs in military resuscitation

Automated external defibrillator (AED) devices have been in routine clinical use since the early 1990s to deliver life-saving shocks to appropriate patients in non-clinical environments. As expectations of survival from out-of-hospital cardiac arrest increase, and evidence incontrovertibly points to reduced timelines as the most crucial factor in achieving return of spontaneous circulation, questions regarding the availability and location of AEDs in the UK military need to be readdressed. This article explores the background of AEDs and reviews their history, life-saving potential and defines current and best practice. It goes on to review the evidence surrounding training and looks to identify knowledge gaps that might be addressed effectively by future research. Finally, it makes recommendations regarding training, availability of AEDs on military bases and locations most likely to deliver good outcomes for military personnel in the future.

Overcoming Spatial and Temporal Barriers to Public Access Defibrillators Via Optimization

BACKGROUND

Immediate access to an automated external defibrillator (AED) increases the chance of survival for out-of-hospital cardiac arrest (OHCA). Current deployment usually considers spatial AED access, assuming AEDs are available 24 h a day.

OBJECTIVES

The goal of this study was to develop an optimization model for AED deployment, accounting for spatial and temporal accessibility, to evaluate if OHCA coverage would improve compared with deployment based on spatial accessibility alone.

METHODS

This study was a retrospective population-based cohort trial using data from the Toronto Regional RescuNET Epistry cardiac arrest database. We identified all nontraumatic public location OHCAs in Toronto, Ontario, Canada (January 2006 through August 2014) and obtained a list of registered AEDs (March 2015) from Toronto Paramedic Services. Coverage loss due to limited temporal access was quantified by comparing the number of OHCAs that occurred within 100 meters of a registered AED (assumed coverage 24 h per day, 7 days per week) with the number that occurred both within 100 meters of a registered AED and when the AED was available (actual coverage). A spatiotemporal optimization model was then developed that determined AED locations to maximize OHCA actual coverage and overcome the reported coverage loss. The coverage gain between the spatiotemporal model and a spatial-only model was computed by using 10-fold cross-validation.

RESULTS

A total of 2,440 nontraumatic public OHCAs and 737 registered AED locations were identified. A total of 451 OHCAs were covered by registered AEDs under assumed coverage 24 h per day, 7 days per week, and 354 OHCAs under actual coverage, representing a coverage loss of 21.5% (p < 0.001). Using the spatiotemporal model to optimize AED deployment, a 25.3% relative increase in actual coverage was achieved compared with the spatial-only approach (p < 0.001).

CONCLUSIONS

One in 5 OHCAs occurred near an inaccessible AED at the time of the OHCA. Potential AED use was significantly improved with a spatiotemporal optimization model guiding deployment.

A Poor Association Between Out-of-Hospital Cardiac Arrest Location and Public Automated External Defibrillator Placement

Introduction

Much attention has been given to the strategic placement of automated external defibrillators (AEDs). The purpose of this study was to examine the correlation of strategically placed AEDs and the actual location of cardiac arrests.

Methods

A retrospective review of data maintained by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), specifically, the Maryland Cardiac Arrest Database and the Maryland AED Registry, was conducted. Location types for AEDs were compared with the locations of out-of-hospital cardiac arrests in Howard County, Maryland. The respective locations were compared using scatter diagrams and r2 statistics.

Results

The r2 statistics for AED location compared with witnessed cardiac arrest and total cardiac arrests were 0.054 and 0.051 respectively, indicating a weak relationship between the two variables in each case. No AEDs were registered in the three most frequently occurring locations for cardiac arrests (private homes, skilled nursing facilities, assisted living facilities) and no cardiac arrests occurred at the locations where AEDs were most commonly placed (community pools, nongovernment public buildings, schools/educational facilities).

Conclusion

A poor association exists between the location of cardiac arrests and the location of AEDs.

LevyMJ, SeamanKG, MillinMG, BissellRA, JenkinsJL. A poor association between out-of-hospital cardiac arrest location and public automated external defibrillator placement. Prehosp Disaster Med. 2013;28(4):1-6.

Automated external defibrillators and secondary prevention of sudden cardiac death among children and adolescents

Sudden cardiac death is devastating at any age, but it is especially so among children and adolescents. This report discusses the outcomes for patients with out-of hospital cardiac arrest (OHCA) and describes public access defibrillation programs in general and those directed at children and adolescents. In addition, the relatively new concept of cardiopulmonary resuscitation (CPR)–automated external defibrillator (AED) programs directed at schools is discussed. Although limited data are available, some of the preliminary data suggest improved OHCA outcomes associated with CPR-AED programs implemented in schools. These early data provide hope for the future potential reduction in the incidence of sudden cardiac deaths in the school setting, not only among children and adolescents, but also among adults.

A first city-wide early defibrillation project in a German city: 5-year results of the Bochum against sudden cardiac arrest study

Background

Immediate defibrillation is the decisive determinant of prognosis in patients suffering from cardiac/circulatory arrest caused by ventricular fibrillation (VF). Therefore, various national and international associations recommend that first responders use defibrillators as soon as possible and also recommend public access to early defibrillation programmes. Here we report the results of the first city-wide early defibrillation project in a large German urban area.

Methods

There were 155 automated external defibrillators (AEDs) put into operation in the Bochum municipal area, and 6,294 people took part in cardiopulmonary resuscitation (CPR) and AED training. Free, accessible AEDs were installed in places with large volumes of people. Additionally, emergency forces were progressively equipped with AEDs.

Results

Twelve AED administrations prior to the arrival of an emergency physician were recorded and analysed over a period of 5 years (08/2004-08/2009). Rhythm analysis via AED demonstrated VF in seven cases, non-malignant dysrhythmias in four cases and asystole in one case. Two of the seven patients with VF were successfully defibrillated and survived cardiac/circulatory arrest without any neurological sequelae. Eight of the 12 AED applications were performed by laymen. The mean time between switching the unit on and applying the electrodes to the patient was 39 seconds (SD +/-20 sec). On average, another 20 seconds elapsed before the AED recommendation of "shock delivery" was displayed, and a total of 96 seconds elapsed before shock administration (± 56 sec).

Conclusion

Consistent with other reports, our findings show that the organisation of a city-wide initiative by a project office combining public access and first-responder defibrillation programmes can be safe, feasible and successful. Our experiences confirm that strategic planning of AED placement is a prerequisite for successful, cost-effective resuscitation.

Ventricular fibrillation and defibrillation

Cardiac arrest in children is not often due to a disturbance in rhythm that is amenable to electrical defibrillation, contrary to the situation in adults. When a shockable rhythm is present, defibrillation using an external electric shock applied at an early stage after pre-oxygenation and chest compressions is of proven efficacy. Success at conversion of ventricular fibrillation is dependent on the delay before delivering the shock and defibrillation efficiency, which is itself a function of thoracic impedance, energy dose and waveform.

Implantable or external defibrillators for individuals at increased risk of cardiac arrest: where cost-effectiveness hits fiscal reality

OBJECTIVES

Implantable cardioverter defibrillators (ICDs) are highly effective at preventing cardiac arrest, but their availability is limited by high cost. Automated external defibrillators (AEDs) are likely to be less effective, but also less expensive. We used decision analysis to evaluate the clinical and economic trade-offs of AEDs, ICDs, and emergency medical services equipped with defibrillators (EMS-D) for reducing cardiac arrest mortality.

METHODS

A Markov model was developed to compare the cost-effectiveness of three strategies in adults meeting entry criteria for the MADIT II Trial: strategy 1, individuals experiencing cardiac arrest are treated by EMS-D; strategy 2, individuals experiencing cardiac arrest are treated with an in-home AED; and strategy 3, individuals receive a prophylactic ICD. The model was then used to quantify the aggregate societal benefit of these three strategies under the conditions of a constrained federal budget.

RESULTS

Compared with EMS-D, in-home AEDs produced a gain of 0.05 quality-adjusted life-years (QALYs) at an incremental cost of $5225 ($104,500 per QALY), while ICDs produced a gain of 0.90 QALYs at a cost of $114,660 ($127,400 per QALY). For every $1 million spent on defibrillators, 1.7 additional QALYs are produced by purchasing AEDs (9.6 QALYs/$million) instead of ICDs (7.9 QALYs/$million). Results were most sensitive to defibrillator complication rates and effectiveness, defibrillator cost, and adults' risk of cardiac arrest.

CONCLUSIONS

Both AEDs and ICDs reduce cardiac arrest mortality, but AEDs are significantly less expensive and less effective. If financial constraints were to lead to rationing of defibrillators, it might be preferable to provide more people with a less effective and less expensive intervention (in-home AEDs) instead of providing fewer people with a more effective and more costly intervention (ICDs).

Cardiac arrest on the links: are we up to par? Availability of automated external defibrillators on golf courses in southeastern Pennsylvania

OBJECTIVES

A growing number of golfers are senior citizens, and it may be predicted that the number of golf-related medical emergencies, including the incidence of cardiac arrest, will increase. This study was designed to survey the level of preparedness of golf courses in southeastern Pennsylvania to respond to cardiac arrest among their members.

METHODS

A telephone survey of all of the 180 golf courses in the area was conducted to determine their type (public/private), volume in rounds per year, presence of automated external defibrillator (AED) devices, number of employees, and percentage of employees with cardiopulmonary resuscitation (CPR) training. Participants also were asked to estimate the time needed to reach the farthest point on their course in order to estimate a maximum time to the application of an AED device.

RESULTS

A total of 131 of 180 golf courses completed the survey (53 private, 78 public) for an overall response rate of 73%. Private courses reported a greater average number of employees with CPR training [private = 9.1, public = 3.6; p = 0.001] and in AED presence [public = 9%, private = 58.5%; p = 0.0001]. Public courses support a higher volume of play than do private courses [public = 32,000, private = 24,000; p = 0.001], yet have far fewer employees [public=25, private=44; p = 0.004]. The longest time necessary to reach the most remote point on the course was between four and five minutes in all courses. Analysis was performed using the Student's t-test and Pearson's Chi-square as appropriate.

CONCLUSION

Neither public nor private golf courses are well equipped to respond to cardiac arrest, but outcomes on public courses likely are to be far worse.

A public access defibrillation programme in non-inpatient hospital areas

INTRODUCTION

Automatic external defibrillators (AED) have proven to be valuable and life saving for out of hospital cardiac arrests. Their use in hospital arrests is less well documented, but they offer the opportunity to improve survival in the hospital setting also.

METHODS

The implementation of a public access defibrillation (PAD) programme at a tertiary care hospital is described, with reference specifically to targeting areas where time from arrest to arrival of defibrillation would be greater than 3 min.

RESULTS

Nine AEDs were placed in areas of the hospital distant from inpatient or outpatient floors. The locations of the AEDs were chosen based on a 3 min walk from currently available defibrillators to all areas of the hospital, including parking garages and walkways from building to building. In this programme AED use in non-inpatient hospital locations resulted in the resuscitation of a patient in ventricular fibrillation.

CONCLUSION

PAD in non-inpatient hospital settings can be life saving and similar programmes should be considered for other hospitals.

Cardiac arrest of nonpatients within hospital public areas

Time to defibrillation is the most important controllable factor for survival. Hospitals also must respond to cardiac arrest in nonpatients (i.e., visitors and staff members) within their public areas. In-hospital cardiac arrest teams may be unaccustomed to resuscitating visitors under what is essentially a prehospital environment. All cardiorespiratory arrests over a 2-year period at the investigators' institution were reviewed. Six of the 749 in-hospital cardiorespiratory arrests (0.8%) occurred in visitors within public areas of the hospital. The average time to defibrillation for the public area cohort was significantly longer than for the in-hospital arrest control group (12.3 vs 2.5 minutes, p <0.0001). Further research is needed to reduce the time to defibrillation and consequently improve survival outcomes for cardiac arrest in hospital public areas.

Cost-effectiveness of in-home automated external defibrillators for individuals at increased risk of sudden cardiac death

BACKGROUND/OBJECTIVE

In-home automated external defibrillators (AEDs) are increasingly recommended as a means for improving survival of cardiac arrests that occur at home. The current study was conducted to explore the relationship between individuals' risk of cardiac arrest and cost-effectiveness of in-home AED deployment.

DESIGN

Markov decision model employing a societal perspective.

PATIENTS

Four hypothetical cohorts of American adults 60 years of age at progressively greater risk for sudden cardiac death (SCD): 1) all adults (annual probability of SCD 0.4%); 2) adults with multiple SCD risk factors (probability 2%); 3) adults with previous myocardial infarction (probability 4%); and 4) adults with ischemic cardiomyopathy unable to receive an implantable defibrillator (probability 6%).

INTERVENTION

Strategy 1: individuals suffering an in-home cardiac arrest were treated with emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals suffering an in-home cardiac arrest received initial treatment with an in-home AED, followed by EMS.

RESULTS

Assuming cardiac arrest survival rates of 15% with EMS-D and 30% with AEDs, the cost per quality-adjusted life-year gained (QALY) of providing in-home AEDs to all adults 60 years of age is 216,000 dollars. Costs of providing in-home AEDs to adults with multiple risk factors (2% probability of SCD), previous myocardial infarction (4% probability), and ischemic cardiomyopathy (6% probability) are 132,000 dollars, 104,000 dollars, and 88,000 dollars, respectively.

CONCLUSIONS

The cost-effectiveness of in-home AEDs is intimately linked to individuals' risk of SCD. However, providing in-home AEDs to all adults over age 60 appears relatively expensive.