Automated External Defibrillation in the Occupational Setting

ACOEM POSITION STATEMENT

Automated External Deﬁbrillation in the Occupational Setting

Larry M. Starr, PhD

On November 13, 2000, President Clinton ing topics: (1) history and overview of AEDs; and fire departments, and police officers.15,16 signed into law H.R. 2498, the Cardiac Ar- (2) epidemiology, morbidity, mortality, and More than 30 years of evidence has also rest Survival Act, designed to expand the incident locations; (3) sudden cardiac arrest shown that little or no training or educa- availability of automated external defibril- (SCA) and the “chain of survival” paradigm; tion is required for proper use,17–20 because lators (AEDs) in public settings and that (4) AED technologies; (5) public-access de- devices have easy-to-follow audio and vi- required the Secretary of the Department fibrillation; and (6) guidance for the use of sual prompt instructions,21–23 or operate au- of Health and Human Services to establish AEDs in occupational settings. tomatically without user decision making af- guidelines for the placement of AEDs in ter pads are placed on the chest of the pa- buildings owned or leased by the federal gov- HISTORY AND OVERVIEW tient. For these reasons, AEDs are commonly ernment. In May 2002, President Bush signed OF AEDS available for voluntary emergency first aid re- into law the Community Access to Emer- sponders and untrained bystanders who may Making its debut in 1979, the term gency Devices Act within H.R. 3448 (sec- be present at the scene of a cardiac arrest. “AED” commonly refers to any device that tions 159, 312, and 313) of the Public Health This open access is promoted in part because analyzes cardiac rhythm and enables the de- Security and Bioterrorism Response Act, and the 2010 International Consensus on Car- livery of an electric shock when necessary.3 on June 12, 2002, he finalized this as Public diopulmonary Resuscitation and Emergency Utilizing solid-state circuitry and microcom- Law 107-188. The provisions authorized the Cardiovascular Care Science with Treatment puter technologies, AEDs identify ventricu- availability of grants to states and localities Recommendations published by the Interna- lar fibrillation (VF) and ventricular tachycar- for the purchase and placement of AEDs in tional Liaison Committee on Resuscitation dia (VT) then voice prompts a user to pre- public places where cardiac arrests are likely (ILCOR), which represents principal resusci- pare for delivery of a shock. Two modes of to occur and encouraged private companies to tation organizations worldwide including the AED are available. An “automated” AED an- purchase AEDs and to train employees in car- American Heart Association (AHA), Euro- alyzes then prompts a user to press a button diopulmonary resuscitation (CPR) and emer- pean Resuscitation Council, and the Heart to deliver a shock. Some AEDs are multi- gency defibrillation. and Stroke Foundation of Canada has rec- functional and can be set to operate in “auto- To support AED federal legislation, ommended that “AED use should not be re- matic” mode, which analyses and delivers a to increase awareness and value, and to of- stricted to trained personnel. Allowing the shock without a user prompt. fer recommendations about AEDs in the use of AEDs by persons without prior formal Annual sales and the total number of occupational setting, the American Col- training can be beneficial and may be lifesav- AEDs in the United States are difficult to con- lege of Occupational and Environmental ing. Because (however) even brief training firm. One study published in 2006 estimated Medicine (ACOEM) has included the AEDs improves performance (eg, speed of use, cor- that more than 200,000 are sold annually for in the Workplace Web site, containing sur- rect pad placement), it is recommended that public use in the United States.4 A 2011 in- vey data, case studies, reference database, training in the use of AEDs be provided.” 24 dustry report estimated that total US sales and other academic and practice resources, As rapid use saves lives, AEDs are in 1996 were approximately 18,645 devices, in their Health and Productivity Management available for lay citizens across a broad spec- and by 2006 total sales had reached more than Center.1 ACOEM also issued in 2001, and trum of private and public locations including 775,000, an increase of 30% per year over the reaffirmed in 2006, a position statement on airports, casinos, community centers, educa- decade.5 Annual revenue forecasts for the de- AEDs in the workplace.2 This document up- tional institutions, and sports and shopping fibrillator market by 2015 are estimated to be dates that statement by addressing the follow- centers, and in tens of thousands of occupa- $1.7 billion in the United States,4 and when tional settings where they are provided for implantable cardioverter defibrillators are in- use by health care and nonmedical first aid This article was prepared by Larry M. Starr, PhD, Or- cluded, in excess of $11 billion globally.6 responders. Indeed, data collected from May ganizational Dynamics Graduate Programs, Uni- Submitting key words, “automated ex- versity of Pennsylvania, Philadelphia, PA, under 1, 2006, to April 30, 2007, from the Resus- ternal defibrillator,” to the National Library the auspices of the ACOEM Council of Scien- citation Outcomes Consortium, an observa- tific Advisors. The article was reviewed by the of Medicine’s pubmed.gov search site pro- tional study involving 13,769 out-of-hospital ACOEM Public Safety Medicine Section, and by duces more than 11,000 scholarly papers cardiac arrests from 10 North American sites the Committee on Policy, Procedures and Public written about AEDs including clinical and Positions. It was approved by the ACOEM Board (8 US and 2 Canadian), showed that overall field reports. Although some devices have of Directors on April 28, 2012. survival to hospital discharge was 7%, sur- ACOEM requires all substantive contributors to its had safety alerts and recalls commonly at- vival with bystander CPR but no AED was documents to disclose any potential competing in- tributed to manufacturer quality control,4,7 9%, and when an AED was used and shock terests, which are carefully considered. ACOEM most research has demonstrated that overall, emphasizes that the judgments expressed herein delivered survival was 38%.25 represents the best available evidence at the time devices are safe, effective, accurate, and in- of publication and shall be considered the posi- creasingly cost-effective.8–12 As AEDs are tion of ACOEM and not the individual opinions easy to transport due to reduced size and EPIDEMIOLOGY, MORBIDITY, of contributing authors. 13 MORTALITY, AND INCIDENT Address correspondence to: Larry M. Starr, weight (less than 7 pounds), and because PhD, Organizational Dynamics Graduate Stud- federal and state legislation enables and pro- LOCATIONS ies, University of Pennsylvania, 3440 Market vides liability protection to acquirers and Cardiovascular diseases (CVD), in- Street, Suite 100, Philadelphia, PA 19104-3335 users,14 AEDs are a standard of care de- cluding coronary heart disease and SCA, re- ([email protected]). vice for health and allied health providers and main significant concerns to general pub- Copyright C 2012 by American College of Occupa- tional and Environmental Medicine are commonly available within medical insti- lic health and the occupational setting in DOI: 10.1097/JOM.0b013e3182677dc8 tutions and for emergency medical services particular. According to the 2011 statistical r 1170 JOEM Volume 54, Number 9, September 2012

update provided by the AHA an estimated rive sooner than EMS; thus, survival to hos- In a systematic review of literature 82,600,000 American adults have one or pital discharge is nearly three times higher through 2008, the factors most correlated more types of CVD.26 Of these, 40,400,000 when an AED is applied by a lay responder with survival to hospital discharge follow- are estimated to be younger than 60 years. after a cardiac arrest in a public location than ing out-of-hospital cardiac arrest were wit- Total CVD includes 76,400,000 people with in a private home where the initial assess- nessed by a bystander, witnessed by EMS, high blood pressure, 16,300,000 with coro- ment and responses are primarily made by applying bystander CPR, being found in nary heart disease, 7,900,000 who experi- EMS (34% vs 12% for arrests at home).39 VF or VT, and achieving return of spon- enced myocardial infarction, 9,000,000 with The consensus of science to correct VF and taneous circulation.47 Without intervention, angina pectoris, 5,700,000 with heart failure, pulseless VT is immediate chest compres- survival following SCA decreases rapidly and 7,000,000 who experienced a stroke. sion followed by a single electric shock with to zero. Several studies have reported that The AHA noted that CVD accounted a controlled dose and duration of energy fol- for each minute of untreated cardiac arrest, for 33.6% (813,804) of all 2,243,712 deaths lowed by resumption of chest compressions. the probability of successful rhythm con- in 2007 (the most recent data available), an If circulation does not return, this is followed version decreases by up to 10%, produc- average of one death every 39 seconds.25 by a sequence of compression and electric ing an equivalent per-minute-death rate.48,49 Data have also indicated that approximately shock with the same or with increasing en- Conversely, survival rates as high as 90% one of every six or 406,351 deaths in the ergy levels.40 have been reported when the collapse- United States resulted from coronary heart Cardiopulmonary resuscitation with- to-defibrillation (“drop-to-shock”) time is disease. The AHA estimate for 2011 is that out electric therapy may sustain a patient in within 1 minute.50–52 785,000 Americans will have a new coronary VF for a short time but only rarely restores an To empirically define the contribution attack, approximately 470,000 will have a organized rhythm. Indeed, performing CPR of each link in the chain of survival, data recurrent attack, and an additional 195,000 in the period of 1.5 to 3 minutes before de- from the Seattle experience were examined silent first myocardial infarctions will be fibrillation does not necessarily improve sur- between 1976 and 1991.49 A best-fit model identified. vival for patients with out-of-hospital VF or demonstrated the following equation: A significant number of cardiac ar- pulseless VT.41,42 And delaying CPR even for Survival rate = 67% at collapse − rests occur in out-of-hospital locations. Out- AED rhythm assessment is associated with 2.3% per minute to CPR − 1.1% per minute of-hospital cardiac arrests data collected by decreased probability of conversion of VF to defibrillation − 2.1% per minute to ACLS emergency medical service programs in Seat- to another rhythm.42,43 As return of an ad- As noted by the authors, tle and King County, Washington, from Jan- equate perfusing rhythm requires immediate uary 1, 1990, through December 31, 1994,27 application of the combination of CPR, de- The regression constant, 67%, rep- revealed that public sites represented 16% of fibrillation, and pharmacotherapy as soon as resents the probability of survival in incidents. The Resuscitation Outcomes Con- possible after arrest, establishing controls to the hypothetical situation in which all sortium examined the period 2005–2007 for support these enhances the probability of sur- treatments are delivered immediately seven US sites (Alabama, Dallas, Iowa, Mil- vival. after collapse to patients with prehos- waukee, Pittsburgh, Portland [Oregon], and pital cardiac arrest . . . . With delays in Seattle and King County) and three Cana- SUDDEN CARDIAC ARREST CPR, defibrillatory shock, and defini- dian sites (Ottawa, Toronto, and Vancouver) AND THE CHAIN-OF-SURVIVAL tive care, the magnitude of the de- and reported 12,930 out-of-hospital cardiac PARADIGM cline in survival rate per minute is the sum of the three coefficients (−2.2%, arrests, of which 15.8% occurred in public Factors contributing to out-of-hospital − − − 49 locations.28 In a 2007 report of the Save survival following SCA have been described 1.1%, 2.1%), or 5.5%. Hearts in Arizona Registry and Education primarily in terms of a time-related, linear Although the chain-of-survival 44,45 program, which reviewed emergency medi- chain-of-survival paradigm. The sequen- paradigm is an established metaphor, some cal services (EMS) first-care reports submit- tial interventions (links) leading to survival argue that it is too simple because the forces ted voluntarily by 30 municipal fire depart- are (1) early recognition and call for EMS; that affect survival are complex.53 For ex- ments responsible for approximately 67% of (2) early initiation of basic life support CPR; ample, when the four survival categories are Arizona’spopulation, the total number of out- (3) early defibrillation (AED); and (4) early examined in more detail, at least 50 “known of-hospital adult arrests of presumed cardiac advanced (cardiac) life support (ALS) pri- or speculative” and additional “yet to be 29 etiology reported statewide was 1097. Of marily involving drug intervention protocols. identified” factors not included in the chain these, 15% occurred in public locations. Following the release of the 2010 Ameri- can be acknowledged as influencing SCA There are several electrical abnormal- can Heart Association Guidelines for Car- survival.54 In addition, only approximately ities that result in SCA, but the majority diopulmonary Resuscitation and Emergency 7.9% of victims survive out-of-hospital of deaths begin with an initial rhythm of Cardiovascular Care, a fifth link, integrated cardiac arrest in the United States (a number 30–32 46 VF. If VF is not treated quickly, nearly post–cardiac arrest care, was added. that has not changed significantly in almost 33 all patients degenerate to asystole, which is Sudden cardiac arrest survival has 30 years47) and there is a fivefold difference 34 fatal. In patients known to have ischemic been described as dependent on the sequen- in survival rate among US communities.38 heart disease, the out-of-hospital cardiac ar- tial availability of the links although more ad- Thus, some commentators have called for a rests incidence of VF and VT is 80% to vanced applications may jump ahead of lesser rethinking of the approach to cardiac arrest 35 90%. ones. For example, if workplace allied health in terms of relevant links,55 and the use of a Over the past three decades, the personnel or the arriving community EMS chain metaphor.56 recorded incidence of VF or pulseless VT responders are not qualified or prepared to as the initial rhythm encountered by EMS in deliver ALS, this link may not be available AED TECHNOLOGIES out-of-hospital cardiac arrests has decreased until the patient arrives at a medical center. significantly,36,37 from approximately 70% to If CPR-trained first aid responders initiate AED Analysis of Rhythms, 23%,25,38 with an overall incidence of 26%.27 chest compressions in conjunction with an Waveforms, Energy Levels, and Ventricular fibrillation or VT is higher for AED, and this is quickly followed by inter- Application bystander-witnessed events in public and oc- vention by ALS-level responses, then timing Automated external defibrillators uti- cupational settings, because bystanders ar- between these links will likely be shorter. lize microprocessors to analyze several

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characteristics of the surface electrocardio- outweigh the number or nature of reports so from the University of Pennsylvania have de- gram signal. Wave frequency, amplitude, federal agencies including FDA and the Oc- signed a contest to find AEDs in the city to and some integrated features such as slope cupational Safety and Health Administration “enable us to build a comprehensive map and or morphology are identified and compared continue to advocate use of these important registry of Philadelphia AEDs that can be with preset values. In an unresponsive, non- lifesaving devices. Indeed, there is no recom- used in emergency situations by the 911 cen- breathing, pulseless patient, an AED will ad- mendation from any federal, state, or medical ter and the public.”69 vise shocks for monomorphic and polymor- agency to make any change to current AED phic VT, supraventricular tachycardia, or VF. clinical practice. GUIDANCE FOR THE USE OF Early AED models offered monopha- AEDS IN OCCUPATIONAL sic or biphasic waveforms. Monophasic SETTINGS waveforms provide current flows in a sin- PUBLIC ACCESS Federal and state government agencies gle direction (polarity). When the rate at DEFIBRILLATION and dozens of professional, safety, and medi- which the pulse falls to zero is gradual, they The public access defibrillation (PAD) cal societies have issued AED position state- are referred to as monophasic damped sinu- concept gained momentum in 1992 when the ments over the past decade.70 Occupational soidal. When the rate is instantaneous, they AHA Task Force on the Future of CPR chal- Safety and Health Administration has estab- are called monophasic truncated exponential. lenged the medical device industry to cre- lished partnerships with the American Asso- Biphasic waveform defibrillators deliver a se- ate AEDs that would make early defibril- ciation of Occupational Health Nurses71 and quence of two pulses in which the second is of lation accessible to the public.61 Public ac- ACOEM,72 in which resources are offered opposite polarity to the first. Although bipha- cess defibrillation applies to all US organiza- to occupational sites including reference to sic damped sinusoidal and biphasic truncated tions including the federal government,62 and the ACOEM AED guidance73 and by citing exponential are both technically possible, al- is defined as out-of-hospital cardiac arrest that “volunteers trained in CPR and the use most all AEDs currently provided are bipha- treated with an AED by persons other than the of AEDs had twice as many victims survive sic truncated exponential devices. community-designated personnel. For exam- compared to . . . volunteers trained only in Reviewing all levels of evidence, IL- ple, the state of Maryland PAD exempts from CPR.”74 The following are updated ACOEM COR and AHA recommended that for a PAD policy “all healthcare facilities, physi- guidance for the use of AEDs in the occupa- biphasic truncated exponential waveform for cian’s offices, dentist’s offices, federal gov- tional setting. defibrillation of pulseless VT/VF cardiac ar- ernment agencies, jurisdictional EMS opera- rest, it is reasonable to start with an energy tional programs, and commercial ambulance Establishment of a Management level of 150 to 200 J.40 Although they note services.”63 that there is insufficient evidence to deter- The rationale for PAD was based on System for the AED Program mine the initial energy level for any other the concern that in many densely populated A management system should be es- biphasic waveform, initial and subsequent areas, traditional EMS responders cannot re- tablished within each organization to have shocks using this waveform should be at 360 spond in sufficiently short time to perform clearly defined lines of responsibility for J. Although there is lower total shock success resuscitation and maximize survival. It was those who oversee and monitor the program. for monophasic defibrillation,57 in the ab- determined that training and equipping lay sence of a biphasic defibrillator, a monopha- responders to use AEDs and provide resus- Medical Direction and sic defibrillator is acceptable and use of a high citation until arrival of EMS was a practical Administrative Control of the AED initial energy (360 J) seems preferable.40 and appropriate solution to that problem. Program Shock success is usually defined as ter- All US states have passed a version of A qualified medical director should be mination of VF 5 seconds after the shock. PAD legislation describing the process of ac- assigned to manage all medical aspects of When defibrillation is required, a single quisition, control, and use of an AED by lay the AED program. Medical direction respon- shock should be provided with resumption responders. Elements commonly addressed sibilities include but are not limited to pro- of chest compressions/CPR immediately af- in state legislation include immunity for res- viding the required written authorization to ter the shock. Chest compressions should not cuers, acquirers, and enablers; training re- acquire the AED and performing a case-by- be delayed for rhythm reanalysis or a pulse quirements for users; medical supervision or case review each time the AED is used in the check immediately after a shock. For second involvement; and EMS notification. A sum- occupational setting. and subsequent biphasic shocks, the same ini- mary of the details of state PAD legislation An administratively qualified person tial energy level is acceptable. is available in AED-information databases should be responsible for the program’s over- such as the National Conference of State all administration and coordination activities. Device “Errors” Legislatures,64 and the National Center for Responsibilities include but are not limited to With the increase in size and compe- Early Defibrillation.65 establishing or integrating the AED program tition of the AED manufacturing and distri- Although survival from PAD has been with an ongoing quality assurance system, bution market over the past decade, the de- shown to be increasing and effective,66 and ensuring compliance with industry-related fibrillator industry has recalled hundreds of although PAD legislation requires AED sales and other regulatory requirements, ensuring thousands of devices and has notified the US to be state-registered, registry compliance proper interface with local EMS, and ensur- Food and Drug Administration (FDA) about and governance continue to show challenges. ing proper education, training, or support for thousands of adverse incident reports includ- For example, a 2004 review of PAD in AED users prior to and following use. ing device failure during a rescue attempt North Carolina indicated that the state EMS that may have contributed to patient harm database contained only 18% of PAD loca- Awareness of and Compliance or death.58 In response, the FDA’s Circu- tions, suggesting that there are a large num- With Federal and State latory System Devices advisory committee ber of AEDs placed in communities that are Regulations, and Policies has discussed whether additional regulatory not registered within the community PAD An occupational AED program must controls may be needed to ensure safe and system.67 Arlington, Texas, with a popula- comply with appropriate federal guidelines reliable performance and long-term moni- tion of more than 365,000, provides a list such as the Cardiac Arrest Survival Act and toring of devices.59,60 Despite these reviews, and map of only 32 AEDs available for “all federal and state PAD legislation. As the de- the remarkable lifesaving benefits continue to businesses.”68 In Philadelphia, researchers tails of state PAD legislation vary, a single

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. r JOEM Volume 54, Number 9, September 2012 Automated External Defibrillation in the Occupational Setting corporate policy for a geographically sepa- Selection and Training of ing guidelines issued by the American Red rated organization may be insufficient unless Responders Cross79 and the National Safety Council80 it addresses all elements where the AEDs Although an AED should be used by include administration of oxygen as part of are placed. An occupational AED program the first available bystander, trained or not, AED and CPR responding. Also, FDA med- should address and be in compliance with all designated occupational first aid respon- ical device and drug policies continue to rec- relevant medical practice insurance require- ders and all occupational health care users ognize emergency oxygen as appropriate for ments and insurance programs for the organi- should receive training that is recognized use without prescription by properly trained 81 zation, and for occupational physicians and and standardized. Topics should include adult personnel. Precautions to minimize spark- nurses, and any programs affecting lay re- (and child, if appropriate) CPR and use of ing from the paddles/pads and avoidance of sponders. the specific AED expected to be available use when high-flow oxygen is directed across 58 and used at the occupational site. Short the chest should be taken. video/computer self-instruction (with mini- When practical, AEDs and ancillary mal or no instructor coaching) that includes supplies should be placed to allow initiation Development of a Written AED of resuscitation and use of the AED (“drop- Program Description for Each synchronous hands-on practice (“practice- while-you-watch”) in basic life support can to-shock” interval) within as brief a period of Location be considered as an effective alternative or re- time as possible following suspected cardiac A written summary of the AED pro- tention method to instructor-led courses. Oc- arrest. As probability of survival reportedly gram should be prepared, distributed, and dis- cupational medical and administrative lead- can decrease by 7% to 10% per minute until 49 cussed with all relevant (eg, administrative, ers are encouraged to identify individuals at defibrillation, a 5-minute response time is safety, security, health care) personnel at an the workplace who would be regularly trained a goal. Estimating the time needed for trans- occupational facility. As state PAD legisla- in CPR/AED and first aid or ALS procedures, port and set up of the AED in various work tion requires registration of AEDs and EMS if appropriate to the work environment. Such areas can help determine whether a proposed notification, and may require additional com- people would be more likely to recognize, location is appropriate. munication to ensure smooth application of respond, and support the responses of by- medical protocols, all information associated standers when SCA or another medical emer- Schedules for Training/Retraining with PAD state requirements and compliance gency occurs. As life support knowledge and skills, should be included in the written program. both basic and advanced, can deteriorate in Selection of AEDs as little as 3 to 6 months, frequent assess- All AEDs must meet federal FDA ments and, when needed, refresher training are recommended to maintain knowledge and Integration With an Overall medical device and federal and state PAD leg- 79 Occupational Emergency islation criteria. Automated external defibril- skills. Response Plan and Coordination lator devices should also meet the most cur- Scheduled Equipment with Local Emergency Medical rent recommendations of ILCOR and AHA. Maintenance and Replacement Services When an older, previously acquired device is available, training of responders should ad- A preventive and postresponse service The AED program should be a com- procedure should be established. Records ponent of the more general plan describing dress any aspects of the device that vary from current recommendations. should be maintained for the AED and all emergency responses at the occupational set- ancillary supplies. ting. Topics addressed by the AED compo- nent should include but not be limited to the Selection of and Placement of awareness and placement of AEDs to ensure AED and Ancillary Supplies Establishment of an AED Quality easy and timely access; procedure for notifi- Ancillary supplies should be available Assurance Program cation of suspected cardiac emergency to oc- for use when managing an occupational SCA The AED program should be incor- cupational medical, trained first aid respon- involving an AED. Examples include but are porated into or have its own quality assur- ders, and bystanders; assessment of scene and not limited to bloodborne pathogens respon- ance program. Elements should include but patient; proper body substance isolation pro- der and cleanup kits to ensure compliance are not limited to medical review by a quali- cedures; CPR and AED response protocols; with body substance isolation procedures,75 fied physician after every AED use; record clinically appropriate patient transport to a CPR barrier masks with one-way valve, AED keeping of all AED-related training, loca- medical facility including how continuation responder kits to support application of self- tions, servicing; and records of all medical of care will be ensured; occupational respon- adhesive defibrillation pads (razor to shave reviews following AED use. In addition, a der and bystander debriefing; equipment re- chest hair and towel to dry the chest after re- method to evaluate the efficacy of the pro- view, service, and replacement; and methods moval of a transdermal patch),76 and a CPR gram against its objectives (educational and to review follow-up care. audio prompting device to guide action and administrative), and a method to improve or Coordination with local EMS should timing sequences of CPR ventilations and sustain critical elements should be provided. be part of an integrated plan. This includes compressions.77,78 but is not limited to review and coordination As dyspnea, hypoxemia, or signs of Cost of Start-up and Continued between EMS protocols and occupational re- heart failure or shock are indications for oxy- Management sponse protocols; communication and logis- gen administration and as use of 100% oxy- Administrators and health care prac- tic support to ensure rapid EMS access to the gen during adult cardiac arrest continues to titioners should be aware that acquiring an occupational site and to patient location; col- be part of the recommended treatment al- AED is one element of a comprehensive and laboration between EMS and occupational gorithm according to ILCOR and AHA,24 a ongoing program. Costs must be identified to responders about on-site patient treatment CPR resuscitation mask with an oxygen port initiate (eg, acquisition of the device, train- and supervision; transition from the occupa- to permit delivery of supplemental oxygen ing, and materials; administration, coordina- tional site to the local medical center; and for the breathing or nonbreathing patient and tion) and to sustain the continued operation integration of occupational follow-up proto- a portable emergency oxygen device should of a program. These ongoing costs should be cols with those at the medical center. be available. To support this, the 2011 train- monitored.

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CONCLUSION http://circ.ahajournals.org/content/95/6/1677. 1726677/pdf/v022p00140.pdf. Accessed Development of a program to acquire long. Accessed January 4, 2012. January 4, 2012. and utilize AEDs is a reasonable, appropriate, 11. Sunde K, Eftestøl T, Askenberg C, Steen PA. 22. Yeung J, Meeks R, Edelson D, Gao F, and increasingly common aspect of manag- Quality assessment of defibrillation and ad- Soar J, Perkin GD. The use of CPR feed- vanced life support using data from the medi- back/prompt devices during training and CPR ing SCA in the occupational setting. How- cal control module of the defibrillator. Resus- performance: a systematic review. Resuscita- ever, acquiring the AED is but one of the citation. 1999;41:237–247. tion. 2009;80:743–751. elements necessary for such a program. To 12. Cram P, Vijan S, Fendrick AM. Cost- 23. Mosesso VN Jr, Shapiro AH, Stein K, Burkett comprehensively address the prevention of effectiveness of automated external defibrilla- K, Wang H. Effects of AED device features on SCA morbidity and mortality among work- tor deployment in selected public locations. performance by untrained laypersons. Resus- ing age adults, a complete AED program is J Gen Intern Med. 2003;18:745–754. citation. 2009;80:1285–1289. recommended. Available at: http:// www.ncbi.nlm.nih.gov/ 24. Hazinski MF, Nolan JP, Billi JP, et al. Part pmc/articles/PMC1494915/?tool=pubmed. 1: Executive summary: 2010 International Accessed January 4, 2012. Consensus on Cardiopulmonary Resuscitation 13. Sudden Cardiac Arrest Foundation. AEDs and Emergency Cardiovascular Care Science REFERENCES on the market. Available at: http://www.sca- with Treatment Recommendations Circula- 1 ACOEM Health and Productivity Manage- aware.org/aeds-on-the-market. Accessed Jan- tion. 2010;122(suppl 2):S250–S275. Available ment Center. AEDs in the workplace. Avail- uary 4, 2012. at: http://circ.ahajournals.org/content/122/16_ able at: http://www.acoem.org/AED.aspx. Ac- 14. National Conference on State Legislatures. suppl_2/S250.long. Accessed January 4, 2012. cessed August 3, 2012. State Laws on Cardiac Arrest and Defib- 25. Weisfeldt ML, Sitlani CM, Ornato JP, et 2. Starr LM. ACOEM Position Statement. Au- rillators. Updated September 2009; material al; Resuscitation Outcomes Consortium In- tomated external defibrillation in the oc- added November 2010. Available at: http:// vestigators. Survival after application of au- cupational setting. J Occup Environ Med. www.ncsl.org/default.aspx?tabid=14506. Ac- tomatic external defibrillators before arrival 2002;44:2–7. (Reaffirmed May 2006) cessed January 4, 2012. of the emergency medical system: evalu- 3. Diack AW, Welborn WS, Rullman RG, Walter 15. White RD, Bunch TJ, Hankins DG. Evolu- ation in the Resuscitation Outcomes Con- CW, Wayne MA. An automatic cardiac re- tion of a community-wide early defibrillation sortium population of 21 million. JAm suscitator for emergency treatment of cardiac programme experience over 13 years using po- Coll Cardiol. 2010;55:1713–1720. Available arrest. Med Instrum. 1979;13:78–83. lice/fire personnel and paramedics as respon- at: http://www.ncbi.nlm.nih.gov/pmc/articles/ 4. Shah JS, Maisel WH. Recalls and safety ders. Resuscitation. 2005;65:279–283. PMC3008654/?tool=pubmed. Accessed Jan- alerts affecting automated external defibrilla- 16. Myerburg RJ, Fenster J, Velex M, et al. uary 4, 2012. tors. JAMA. 2006;296:655–660. Impact of community-wide police car deploy- 26. Roger VL, Go AS, Lloyd-Jones DM, et al; 5. Cardiac defibrillators. Emerging markets ment of automated external defibrillators on American Heart Association Statistics Com- (Brazil, Russia, India, China, South Africa and survival from out-of-hospital cardiac arrest. mittee and Stroke Statistics Subcommittee. South Korea): current trends, estimates and Circulation. 2002;106:1058–64. Available at: Heart disease and stroke statistics—2011 up- forecasts, market growth analysis 2009–2015. http://circ.ahajournals.org/content/106/9/1058. date: a report from the American Heart Asso- Axis Research Mind; February 2011. Report long. Accessed January 4, 2012. ciation. Circulation. 2011;123:e18-e209. Code: ARMMR140. 17. Cummins RO, Schubach JA, Litwin PE, 27. Becker L, Eisenberg M, Fahrenbruch C, Cobb 6. Global Industry Analysts, Inc. Global car- Hearne TR. Training lay persons to use au- L. Public locations of cardiac arrest. Impli- diac defibrillators market to exceed US tomatic external defibrillators: success of ini- cations for public access defibrillation. Cir- $11 Billion by 2015, according to a new tial training and one-year retention skills. Am culation. 1998; 97:2106–2109. Available at: report by Global Industry Analysts, Inc. JEmergMed. 1989;7:143–149. http://circ.ahajournals.org/content/97/21/2106. 2011. Available at: http://www.prweb.com/ 18. Hazinski MF, Idris AH, Kerber RE, et al. Lay long. Accessed January 4, 2012. releases/cardiac_defibrillators/implantable_ rescuer automated external defibrillator (“pub- 28. Weisfeldt ML, Everson-Stewart S, Sitlani external/prweb8061579.htm. Accessed lic access defibrillation”) programs: lessons C, et al; Resuscitation Outcomes Consor- January 4, 2012. learned from an international multicenter tium (ROC) Investigators. Ventricular tach- 7. Shuren J. Letter to manufacturers of external trial: advisory statement from the American yarrhythmias after cardiac arrest in public defibrillators about developing safer products. Heart Association Emergency Cardiovascular versus at home. NEnglJMed.2011;364: Published November 15, 2010. Available Committee; the Council on Cardiopulmonary, 313–321. at: http://www.fda.gov/MedicalDevices/ Perioperative, and Critical Care; and the 29. Vadeboncoeur T, Bobrow BJ, Clark L, et al. ResourcesforYou/Industry/ucm233396.htm. Council on Clinical Cardiology. Circulation. The Save Hearts in Arizona Registry and Edu- Accessed January 4, 2012. 2005;111:3336–3340. Available at: http:// cation (SHARE) program: who is performing 8. Cummins RO, Eisenberg M, Bergner L, Mur- circ.ahajournals.org/content/111/24/3336.long. CPR and where are they doing it? Resuscita- ray JA. Sensitivity, accuracy, and safety of Accessed January 4, 2012. tion. 2007;75:68–75. an automatic external defibrillator. Lancet. 19. Gundry JW, Comess KA, DeRook FA, Jor- 30. Zipes DP, Wellens HJ. Sudden car- 1984;2:318–320. genson D, Bardy GH. Comparison of naive diac death. Circulation. 1998;98:2334– 9. Cummins RO, Austin D Jr, Graves JR, Ham- sixth-grade children with trained profession- 2351. Available at: http://circ.ahajournals.org/ bly C. An innovative approach to medical con- als in the use of an automated exter- content/98/21/2334.long. Accessed January 3, trol: semiautomatic defibrillators with sold- nal defibrillator. Circulation. 1999;100:1703– 2012. state memory modules for recording cardiac 1707. Available at: http://circ.ahajournals. 31. National Center for Health Statistics. Ad- arrest events. Ann Emerg Med. 1988;17:818– org/content/100/16/1703.long. Accessed Jan- vance report of final mortality statistics, 1995. 824. uary 4, 2012. Monthly Vital Statistics Report. 1997;45:S2. 10. Kerber RE, Becker LB, Bourland JD, et al. 20. Yeung J, Okamoto D, Soar J, Perkins GD. AED 32. Lombardi G, Gallagher J, Gennis P. Outcome Automatic external defibrillators for public training and its impact on skill acquisition, re- of out-of-hospital cardiac arrest in New York access defibrillation: recommendations for tention and performance—a systematic review City. The Prehospital Arrest Survival Evalu- specifying and reporting arrhythmia analysis of alternative training methods. Resuscitation. ation (PHASE) Study. JAMA. 1994;271:678– algorithm performance, incorporating new 2011;82:657–664. 683. waveforms, and enhancing safety. A statement 21. Williamson LJ, Larsen PD, Tzeng YC, 33. Hallstrom AP, Eisenbrg MS, Bergner L. for health professionals from the American Galletly DC. Effect of automatic external The persistence of ventricular fibrillation and Heart Association Task Force on Auto- defibrillator audio prompts on cardiopul- its implications for evaluating EMS. Emerg matic External Defibrillation, Subcommittee monary resuscitation performance. Emerg Health Serv Q. 1982;1:41–49. on AED Safety and Efficacy. Circula- Med J. 2005;22:140–143. Available at: http:// 34. Becker LB, Ostrander MP, Barrett J, Kondos tion. 1997;95:1677–1682. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC GT. Outcome of CPR in a large metropolitan

1174 C 2012 American College of Occupational and Environmental Medicine

area: where are the survivors? Ann Emerg Med. tee, American Heart Association. Circulation. 59. US Food and Drug Administration. FDA 1991;20:335–361. 1991;83:1832–1847. Executive Summary, Circulatory System De- 35. Millard WM, DeMaio VJ, Grant PT, Yahn 46. Field JM, Hazinski MF, Sayre MR, et al. Part vices Panel. Automated External Defibrillator S. Locations of cardiac arrest in a large 1: Executive summary: 2010 American Heart 515(i) Reclassification. Published January urban center [abstract]. Acad Emerg Med. Association Guidelines for Cardiopulmonary 25, 2010. Available at: http://www.fda.gov/ 2000;7:430–431. Resuscitation and Emergency Cardiovascular downloads/AdvisoryCommittees/Committees 36. Cobb LA, Fahrenbruch CE, Olsufka M, Care. Circulation. 2010;122:(suppl 3):S640– MeetingMaterials/MedicalDevices/Medical Copass MK. Changing incidence of out- S656. DevicesAdvisoryCommittee/Circulatory of-hospital ventricular fibrillation, 1980– 47. Sasson C, Rogers MA, Dahl J, Keller- SystemDevicesPanel/UCM240579.pdf. 2000. JAMA. 2002;288:3008–3013. Avail- mann AL. Predictors of survival from out- Accessed January 4, 2012. able at: http://jama.ama-assn.org/content/288/ of-hospital cardiac arrest: a systematic review 60. US Department of Health and Human 23/3008.long. Accessed January 4, 2012. and meta-analysis. Circulation. 2010;3:63–81. Services, Public Health Service. Summary 37. Becker L, Gold LS, Eisenberg M, White L, Available at: http://circoutcomes.ahajournals. from the Circulatory System Devices Panel Hearne T, Rea T. Ventricular fibrillation in org/content/3/1/63.long. Accessed January 4, Meeting—January 25, 2011. Available at: King County, Washington: a 30-year perspec- 2011. http://www.fda.gov/downloads/Advisory tive. Resuscitation. 2008;79:22–27. 48. DeMaio VJ, Steill IG, Wells GA, et al. Po- Committees/CommitteesMeetingMaterials/ 38. Nichol G, Thomas E, Callaway CW, et al. tential impact of public access defibrillation MedicalDevices/MedicalDevicesAdvisory Regional variation in out-of-hospital car- based on cardiac arrest locations [abstract]. Committee/CirculatorySystemDevicesPanel/ diac arrest incidence and outcome. JAMA. Acad Emerg Med. 2000;8:415. UCM241780.pdf. Accessed January 4, 2012. 2008;300:1423–1431. Erratum in: JAMA. 49. Larsen MP, Eisenberg MS, Cummins RO, 61. Cobb LA, Eliastam M, Kerber RE, et al. 2008;300:1763. Available at: http://www.ncbi. Hallstrom AP. Predicting survival from out- Report of the American Heart Associ- nlm.nih.gov/pmc/articles/PMC3187919/?tool of-hospital cardiac arrest: a graphic model. ation Task Force on the Future of Car- =pubmed. Accessed January 4, 2012. Ann Emerg Med. 1993;22:1652–1658. diopulmonary Resuscitation. Circulation. 39. Niemann JT, Criley JM, Rosborough JP, 50. Stults KR, Brown DD, Schug VL, Bean JA. 1992;85:2346–2355. Available at: http:// Niskanen RA, Alferness C. Predictive indices Prehospital defibrillation performed by emer- circ.ahajournals.org/content/85/6/2346.long. of successful cardiac resuscitation after longed gency medical technicians in rural communi- Accessed January 4, 2012. arrest and experimental cardiopulmonary re- ties. N Engl J Med. 1984;310:219–223. 62. US Department of Health and Human Ser- suscitation. Ann Emerg Med. 1985;14:521– 51. Eisenberg MS, Copass MK, Hallstrom AP, vices and General Services Administra- 528. et al. Treatment of out-of-hospital cardiac tion. Guidelines for public access defibrilla- 40. Jacobs I, Sunde K, Deakin CD, et al. Part arrests with rapid defibrillation by emer- tion programs in federal facilities. Federal 6: Defibrillation: 2010 International Con- gency medical technicians. NEnglJMed. Register. 2001;66:28495–28511. Available sensus on Cardiopulmonary Resuscitation 1980;302:1379–1383. at: http://www.foh.dhhs.gov/whatwedo/AED/ and Emergency Cardiovascular Care Science 52. Bailey ED, Wydro GC, Cone DC. Termination HHSAED.ASP. Accessed January 4, 2012. with Treatment Recommendations. Circula- of resuscitation in the prehospital setting for 63. Maryland Institute for Emergency Medical tion. 2010;122(suppl 2):S325–S337. Avail- adult patients suffering nontraumatic cardiac Services. Automated External Defibrilla- able at: http://circ.ahajournals.org/content/ arrest. National Association of EMS Physi- tion (AED) Program. Available at: http:// 122/16_suppl_2/S325.long. Accessed January cians Standards and Clinical Practice Commit- www.miemss.org/home/Programs/MDPublic 4, 2012. tee. Prehosp Emerg Med. 2000;4:190–195. AccessAutomatedExternalDefibrillator/tabid/ 53. Starr LM, Braslow A. New thinking about 85/Default.aspx. Accessed January 4, 2012. 41. Baker PW, Conway J, Cotton C, et al. De- SCA survival: relying on the chain of fibrillation or cardiopulmonary resuscitation 64. National Conference on State Legislatures, survival model alone is not enough to im- first for patients with out-of-hospital cardiac Washington, DC. State Laws on Heart prove SCA survival in your community. J arrests found by paramedics to be in ventric- Attacks and Defibrillators: encouraging a Emerg Med Serv. Available at: http://www. ular fibrillation? A randomised control trial. community access response. Available at: jems.com/article/patient-care/new-thinking- Resuscitation. 2008;79:424–431. http://www.ncsl.org/programs/health/aed.htm. about-sca-surviva. Published February 28, Accessed January 4, 2012. 42. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. 2011. CPR before defibrillation in out-of-hospital 65. National Center for Early Defibrillation. 54. Eisenberg MS. Resuscitate! How Your Com- cardiac arrest: a randomized trial. Emerg Med Understanding Legal Issues/Chart on State munity Can Improve Survival From Sudden Australas. 2005;17:39–45. Erratum in: Emerg AED Laws. Available at: http://www.early- Cardiac Arrest. Seattle, WA: University of Med Australas. 2009;21:430. defib.org/03_06_02.html. Accessed August 9, Washington Press; 2009. 43. Eftestøl T, Sunde K, Steen PA. Effects of 2012. 55. Bardy GH. A critic’s assessment of our interrupting precordial compressions on the 66. Culley LL, Rea TD, Murray JA, et al. Pub- approach to cardiac arrest. NEnglJMed. calculated probability of defibrillation success lic access defibrillation in out-of-hospital 2011;364:374–337. Available at: http://www. during out-of-hospital cardiac arrest. Circu- cardiac arrest: a community-based study. nejm.org/doi/full/10.1056/NEJMe1012554. lation. 2002;105:2270–2273. Available at: Circulation. 2004;109:1859–1863. Avail- Accessed January 4, 2012. http://circ.ahajournals.org/content/105/19/2270. able at: http://circ.ahajournals.org/content/ long. Accessed January 4, 2012. 56. Starr LM. Rethinking SCA at work. Occup 109/15/1859.long. Accessed January 4, 2012. Health Safety. 2007;76:55–63. 44. Guidelines for cardiopulmonary resuscita- 67. Myers JB, French D, Webb W. Lack of in- tion and emergency cardiovascular care.Part 57. van Alem AP, Chapman FW, Lank P, Hart tegration of automated external defibrillators 12: From science to survival: strengthen- AA, Koster R. A prospective, randomised with EMS response may reduce lifesaving po- ing the chain of survival in every commu- and blinded comparison of first shock suc- tential of public-access defibrillation. Prehosp nity. ECC in the community: how to en- cess of monophasic and biphasic waveforms in Emerg Care. 2005;9:339–43. sure effectiveness. Circulation. 2000;102:I- out-of-hospital cardiac arrest. Resuscitation. 68. Arlington Texas Fire Department Pub- 358–370. Available at: http://circ.ahajournals. 2003;58:17–24. lic Access Defibrillation. AED program: org/content/102/suppl_1/I-358.full. Accessed 58. Center for Devices and Radiological automatic external defibrillators in Ar- January 4, 2012. Health, US Food and Drug Administra- lington. Available at: http://www.arling 45. Cummins RO, Ornato JP, Thies WH, Pepe PE. tion. External Defibrillator Improvement tontx.gov/fire/PAD/aed_arlington.html. Improving survival from sudden cardiac ar- Initiative. Published November 2010. Accessed January 4, 2012. rest: the “chain of survival” concept. A state- Available at: http://www.fda.gov/downloads/ 69. University of Pennsylvania. Welcome to ment for health professionals from the Ad- MedicalDevices/ProductsandMedicalProcedures/ the MyHeartMap Challenge. Improving vanced Cardiac Life Support Subcommittee CardiovascularDevices/ExternalDefibrillators/ AED awareness and access to save lives. and the Emergency Cardiac Care Commit- UCM233824.pdf. Accessed January 4, 2012. Available at: http://www.med.upenn.edu/

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myheartmap/index.html. Accessed January 4, 74. Hallstrom A, Ornato J, Weisfeldt M, audio-prompts. Resuscitation. 2005;64:297– 2012. et al. Public-access defibrillation and sur- 301. 70. Sudden Cardiac Arrest Foundation. Posi- vival after out-of-hospital cardiac arrest. N 78. Mancini ME, Soar J, Bhanji F, et al. tion statements. Available at: http://www.sca- Engl J Med. 2004;351:637–646. Available Part 12: Education, implementation, and aware.org/position-statements. Accessed Jan- at: http://www.nejm.org/doi/full/10.1056/NEJ teams: 2010 International Consensus on uary 4, 2012. Moa040566. Accessed January 4, 2012. Cardiopulmonary Resuscitation and Emer- 71. US Department of Labor, Occupational 75. Bloodborne Pathogens Standard. Occupa- gency Cardiovascular Care Science With Health and Safety Administration. Amer- tional Safety and Health Administration. CFR Treatment Recommendations. Circulation. ican Association of Occupational Health 1910.1030. Available at: http://www.osha.gov/ 2010;122(suppl 2):S539–S581. Available at: Nurses (AAOHN). Available at: http:// pls/oshaweb/owadisp.show_document?p_table= http://circ.ahajournals.org/content/122/16_ www.osha.gov/dcsp/alliances/aaohn/aaohn. standards&p_id=10051. Accessed January 4, suppl_2/S539.long. Accessed January 4, html. Accessed January 4, 2012. 2012. 2012. 72. US Department of Labor. Agreement estab- 76. Guidelines 2000 for Cardiopulmonary Re- 79. American Red Cross. Administering Emer- lishing an alliance between the Occupational suscitation and Emergency Cardiovascular gency Oxygen Instructor’sManual 2011.Yard- Safety and Health Administration, US Care. Part 4: The automated external defib- ley, PA: StayWell Health & Safety Solutions Department of Labor and the American rillator: key link in the chain of survival. Publishers; 2011. College of Occupational and Environmental The American Heart Association in Col- 80. National Safety Council. NSC Basic Life Sup- Medicine. Available at: http://www.osha.gov/ laboration with the International Liaison port for Health Care and Professional Res- dcsp/alliances/acoem/acoem_final_20030319. Committee on Resuscitation. Circulation. cuers Textbook 2011. Itasca, IL: NSC; 2011. html. Accessed January 4, 2012. 2000;102(suppl):I60–I76. Available at: 81. US Department of Health and Human Ser- 73. US Department of Labor, Occupational Safety http://circ.ahajournals.org/content/102/suppl_ vices, Food and Drug Administration. FDL Is- and Health Administration. We can help, 1/I-60.full. Accessed January 4, 2012. sue 94-02, CPGM-DB Chapter 56, Drug Qual- automated external defibrillators (AEDs). 77. Chiang WC, Chen WJ, Chen SY, et al. Better ity Assurance, 21 CFR Part 3, Oxygen and its Available at: http://www.osha.gov/SLTC/ adherence to the guidelines during cardiopul- Delivery Systems. Washington, DC: US Dept aed/index.html. Accessed January 4, 2012. monary resuscitation through the provision of of Health and Human Services; 1995.

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