Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)

Economic evaluation of automated external defibrillator deployment in public settings for out-of-hospital cardiac arrest: a systematic review

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major issue in aging populations. The use of automatic external defibrillators (AEDs) in public places improves cardiac arrest survival rates. The purpose of this study is to review economic evaluation studies of the use of AED technology in public settings for cardiac arrest resuscitation.

METHODS

Our search covered 1990-2021 and included PubMed, Cochrane Library, Embase, Scopus, and Web of Science. We included studies that analyzed cost-effectiveness, cost-utility and cost-benefit of the AED technology. Also, we performed the quality assessment of the studies through the checklist of quality assessment standard of health economic studies (QHES).

RESULTS

Our inclusion criteria were met by 25 studies. AEDs are found to be cost-effective in places with a high occurrence of cardiac arrest. In addition, proper integration of drones with AEDs into existing systems has the potential to significantly improve OHCA survival rates.

CONCLUSION

The present study found that putting AEDs in high-cardiac arrest and crowded areas reduces average costs. Despite this, the costs associated with acquiring and maintaining AEDs prevent their widespread use. Further research is needed to evaluate feasibility and explore innovative strategies for AED maintenance and accessibility.

Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided.

OBJECTIVE

This review evaluated the scope of community-based OHCA interventions in resource-limited settings.

METHODS

Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country).

RESULTS

Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries.

CONCLUSIONS

Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

A five-year retrospective study of out-of-hospital cardiac arrest in a north-east Italian urban area

BACKGROUND

The reporting and analysing of data of out-of-hospital cardiac arrests encourages the quality improvement of the emergency medical services. For this reason, the establishment of a sufficiently large patient database is intended to allow analysis of resuscitation treatments for out-of-hospital cardiac arrests and performances of different emergency medical services.

AIMS

The aim of this study was to describe the demographics, characteristics, outcomes and determinant factors of survival for patients who suffered an out-of-hospital cardiac arrest.

METHODS

this was a retrospective study including all out-of-hospital cardiac arrest cases treated by the emergency medical service in the district of Udine (Italy) from 1 January 2010-31 December 2014.

RESULTS

A total of 1105 out-of-hospital cardiac arrest patients were attended by the emergency medical service. Of these, 489 (44.2%) underwent cardiopulmonary resuscitation, and return of spontaneous circulation was achieved in 142 patients (29%). There was a male predominance overall, and the main age was 72.6 years (standard deviation 17.9). Cardiopulmonary resuscitation before emergency medical service arrival was performed on 62 cases (44%) in the return of spontaneous circulation group, and on 115 cases (33%) in the no return of spontaneous circulation group ( p<0.024). Among the 142 cases of return of spontaneous circulation, 29 (5.9%) survived to hospital discharge. There was a smaller likelihood of return of spontaneous circulation when patients were female (odds ratio 0.61, 0.40-0.93). Patients who had an out-of-hospital cardiac arrest with an initial shockable rhythm (odds ratio 6.33, 3.86-10.39) or an age <60 years (odds ratio 2.91, 1.86-4.57) had a greater likelihood of return of spontaneous circulation. In addition, bystander cardiopulmonary resuscitation (odds ratio 1.56, 1.04-2.33) was associated with an increased chance of return of spontaneous circulation.

CONCLUSION

The incidence of out-of-hospital cardiac arrest and survival rate lies within the known range. A wider database is necessary to achieve a better knowledge of out-of-hospital cardiac arrest and to drive future investments in the healthcare system.

Self-learning basic life support: A randomised controlled trial on learning conditions

AIM OF THE STUDY

To investigate whether pure self-learning without instructor support, resulted in the same BLS-competencies as facilitator-led learning, when using the same commercially available video BLS teaching kit.

METHODS

First-year medical students were randomised to either BLS self-learning without supervision or facilitator-led BLS-teaching. Both groups used the MiniAnne kit (Laerdal Medical, Stavanger, Norway) in the students' local language. Directly after the teaching and three months later, all participants were tested on their BLS-competencies in a simulated scenario, using the Resusci Anne SkillReporter™ (Laerdal Medical, Stavanger, Norway). The primary outcome was percentage of correct cardiac compressions three months after the teaching. Secondary outcomes were all other BLS parameters recorded by the SkillReporter and parameters from a BLS-competence rating form.

RESULTS

240 students were assessed at baseline and 152 students participated in the 3-month follow-up. For our primary outcome, the percentage of correct compressions, we found a median of 48% (interquartile range (IQR) 10-83) for facilitator-led learning vs. 42% (IQR 14-81) for self-learning (p = 0.770) directly after the teaching. In the 3-month follow-up, the rate of correct compressions dropped to 28% (IQR 6-59) for facilitator-led learning (p = 0.043) and did not change significantly in the self-learning group (47% (IQR 12-78), p = 0.729).

CONCLUSIONS

Self-learning is not inferior to facilitator-led learning in the short term. Self-learning resulted in a better retention of BLS-skills three months after training compared to facilitator-led training.

Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review

Public access defibrillation initiatives make automated external defibrillators available to the public. This facilitates earlier defibrillation of out-of-hospital cardiac arrest victims and could save many lives. It is currently only used for a minority of cases. The aim of this systematic review was to identify barriers and facilitators to public access defibrillation. A comprehensive literature review was undertaken defining formal search terms for a systematic review of the literature in March 2017. Studies were included if they considered reasons affecting the likelihood of public access defibrillation and presented original data. An electronic search strategy was devised searching MEDLINE and EMBASE, supplemented by bibliography and related-article searches. Given the low-quality and observational nature of the majority of articles, a narrative review was performed. Sixty-four articles were identified in the initial literature search. An additional four unique articles were identified from the electronic search strategies. The following themes were identified related to public access defibrillation: knowledge and awareness; willingness to use; acquisition and maintenance; availability and accessibility; training issues; registration and regulation; medicolegal issues; emergency medical services dispatch-assisted use of automated external defibrillators; automated external defibrillator-locator systems; demographic factors; other behavioural factors. In conclusion, several barriers and facilitators to public access defibrillation deployment were identified. However, the evidence is of very low quality and there is not enough information to inform changes in practice. This is an area in urgent need of further high-quality research if public access defibrillation is to be increased and more lives saved. PROSPERO registration number CRD42016035543.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Defibrillation in rural areas

AIM OF THE STUDY

Automated external defibrillation (AED) and public access defibrillation (PAD) have become cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in rural areas.

METHODS

A Medline search was performed with the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional articles found by manually searching references, 92 articles were included in this nonsystematic review.

RESULTS

Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-hospital cardiac arrest.

CONCLUSIONS

In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.

Dual dispatch early defibrillation in out-of-hospital cardiac arrest in a mixed urban-rural population

AIMS

The effects of a system based on minimally trained first responders (FR) dispatched simultaneously with the emergency medical services (EMS) of the local hospital in a mixed urban and rural area in Northwestern Switzerland were examined.

METHODS AND RESULTS

In this prospective study 500 voluntary fire fighters received a 4-h training in basic-life-support using automated-external-defibrillation (AED). FR and EMS were simultaneously dispatched in a two-tier rescue system. During the years 2001-2008, response times, resuscitation interventions and outcomes were monitored. 1334 emergencies were included. The FR reached the patients (mean age 60.4 ± 19 years; 65% male) within 6 ± 3 min after emergency calls compared to 12 ± 5 min by the EMS (p<0.0001). Seventy-six percent of the 297 OHCAs occurred at home. Only 3 emergencies with resuscitation attempts occurred at the main railway station equipped with an on-site AED. FR were on the scene before arrival of the EMS in 1166 (87.4%) cases. Of these, the FR used AED in 611 patients for monitoring or defibrillation. CPR was initiated by the FR in 164 (68.9% of 238 resuscitated patients). 124 patients were defibrillated, of whom 93 (75.0%) were defibrillated first by the FR. Eighteen patients (of whom 13 were defibrillated by the FR) were discharged from hospital in good neurological condition.

CONCLUSIONS

Minimally trained fire fighters integrated in an EMS as FR contributed substantially to an increase of the survival rate of OHCAs in a mixed urban and rural area.

The effect of the AED and AED programs on survival of individuals, groups and populations

OBJECTIVE

The automated external defibrillator (AED) is a tool that contributes to survival with mixed outcomes. This review assesses the effectiveness of the AED, consistencies and variations among studies, and how varying outcomes can be resolved.

METHODS

A worksheet for the International Liaison Committee on Resuscitation (ILCOR) 2010 science review focused on hospital survival in AED programs was the foundation of the articles reviewed. Articles identified in the search covering a broader range of topics were added. All articles were read by at least two authors; consensus discussions resolved differences.

RESULTS

AED use developed sequentially. Use of AEDs by emergency medical technicians (EMTs) compared to manual defibrillators showed equal or superior survival. AED use was extended to trained responders likely to be near victims, such as fire/rescue, police, airline attendants, and casino security guards, with improvement in all venues but not all programs. Broad public access initiatives demonstrated increased survival despite low rates of AED use. Home AED programs have not improved survival; in-hospital trials have had mixed results. Successful programs have placed devices in high-risk sites, maintained the AEDs, recruited a team with a duty to respond, and conducted ongoing assessment of the program.

CONCLUSION

The AED can affect survival among patients with sudden ventricular fibrillation (VF). Components of AED programs that affect outcome include the operator, location, the emergency response system, ongoing maintenance and evaluation. Comparing outcomes is complicated by variations in definitions of populations and variables. The effect of AEDs on individuals can be dramatic, but the effect on populations is limited.

Cardiac deatH prevention by aUtomated defibrillatoRs in ChurcHes: rationale and design of the CHURCH trial

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

A national scheme for public access defibrillation in England and Wales: early results

BACKGROUND

Automated external defibrillators (AEDs) operated by lay persons are used in the UK in a National Defibrillator Programme promoting public access defibrillation (PAD).

METHODS

Two strategies are used: (1) Static AEDs installed permanently in busy public places operated by those working nearby. (2) Mobile AEDs operated by community first responders (CFRs) who travel to the casualty.

RESULTS

One thousand five hundred and thirty resuscitation attempts. With static AEDs, return of spontaneous circulation (ROSC) was achieved in 170/437 (39%) patients, hospital discharge in 113/437 (26%). With mobile AEDs, ROSC was achieved in 110/1093 (10%), hospital discharge in 32 (2.9%) (P<0.001 for both variables). More shocks were administered with static AEDS 347/437 (79%) than mobile AEDs 388/1093 (35.5%) P<0.001. Highly significant advantages existed for witnessed arrests, administration of shocks, bystander CPR before arrival of AED and short delays to start CPR and attach AED. These factors were more common with static AEDs. For CFRs, patients at home did less well than those at other locations for ROSC (P<0.001) and survival (P=.006). Patients at home were older, more arrests were unwitnessed, fewer shocks were given, delays to start CPR and attach electrodes were longer.

CONCLUSIONS

PAD is a highly effective strategy for patients with sudden cardiac arrest due to ventricular fibrillation who arrest in public places where AEDs are installed. Community responders who travel with an AED are less effective, but offer some prospect of resuscitation for many patients who would otherwise receive no treatment. Both strategies merit continuing development.

Home use of automated external defibrillators for sudden cardiac arrest

BACKGROUND

The most common location of out-of-hospital sudden cardiac arrest is the home, a situation in which emergency medical services are challenged to provide timely care. Consequently, home use of an automated external defibrillator (AED) might offer an opportunity to improve survival for patients at risk.

METHODS

We randomly assigned 7001 patients with previous anterior-wall myocardial infarction who were not candidates for an implantable cardioverter-defibrillator to receive one of two responses to sudden cardiac arrest occurring at home: either the control response (calling emergency medical services and performing cardiopulmonary resuscitation [CPR]) or the use of an AED, followed by calling emergency medical services and performing CPR. The primary outcome was death from any cause.

RESULTS

The median age of the patients was 62 years; 17% were women. The median follow-up was 37.3 months. Overall, 450 patients died: 228 of 3506 patients (6.5%) in the control group and 222 of 3495 patients (6.4%) in the AED group (hazard ratio, 0.97; 95% confidence interval, 0.81 to 1.17; P=0.77). Mortality did not differ significantly in major prespecified subgroups. Only 160 deaths (35.6%) were considered to be from sudden cardiac arrest from tachyarrhythmia. Of these deaths, 117 occurred at home; 58 at-home events were witnessed. AEDs were used in 32 patients. Of these patients, 14 received an appropriate shock, and 4 survived to hospital discharge. There were no documented inappropriate shocks.

CONCLUSIONS

For survivors of anterior-wall myocardial infarction who were not candidates for implantation of a cardioverter-defibrillator, access to a home AED did not significantly improve overall survival, as compared with reliance on conventional resuscitation methods. (ClinicalTrials.gov number, NCT00047411 [ClinicalTrials.gov].).

[Public access defibrillation. Limited use by trained first responders and laymen]

As ventricular fibrillation is the most frequent initial heart rhythm causing out-of-hospital sudden cardiac arrest, defibrillation is of essential significance. Automated external defibrillators (AEDs) have been available for some years and as a result defibrillation can be carried out by individuals other than physicians and healthcare providers such as trained first responders and untrained lay rescuers. This so-called public access defibrillation nourished hope of progress in the treatment of sudden cardiac arrest. However, several limitations exist, such as low frequency of sudden cardiac arrest in public, rare use of publicly placed AEDs, low cost effectiveness, legal requirements and insufficient public willingness to help. Due to these restrictions of public access defibrillation other measures are more promising than the attempt at general distribution of AEDs. These measures are primary or secondary prophylaxis of sudden cardiac arrest, general knowledge of adequate activation of emergency medical services, implementation of first responder teams equipped with AEDs and particularly a better education in and application of the well-established principles of cardiopulmonary resuscitation.