13 Public Access Defibrillation

Chapter 13 / Public Access Defibrillation 229 13 Public Access Defibrillation

Vincent N. Mosesso, Jr., MD, FACEP, Mary M. Newman, BS, and Kristin R. Hanson, BA, EMT

CONTENTS INTRODUCTION THE CHALLENGE OF PROVIDING EARLY DEFIBRILLATION AUTOMATED EXTERNAL DEFIBRILLATORS STRATEGIES FOR EARLY DEFIBRILLATION EARLY DEFIBRILLATION PROGRAMS AND MODELS ESTABLISHING A COMMUNITY-BASED AED PROGRAM ESTABLISHING AN ON-SITE AED PROGRAM SUMMARY REFERENCES

INTRODUCTION The value of early intervention in critically ill patients has long been recognized. As early as the 1700s, scientists recognized the value of mouth-to-mouth respiration and the medical benefits of electricity (1). In the modern era, advances in resuscitation began to proliferate. In 1947, Claude Beck successfully resuscitated a 14-year-old boy through the use of open chest massage and an alternating current (AC) defibrillator, the kind that is used in wall outlets. In 1956, Paul Zoll demonstrated the effectiveness of closed chest massage with the use of an AC defibrillator. In the late 1950s, Peter Safar, William Kouwenhoven, James Jude and others began to study sudden cardiac arrest (CA) and in 1960, they demonstrated the efficacy of mouth-to-mouth ventilation and closed chest cardiac massage (2). In 1961, Bernard Lown demonstrated the superiority of direct current (DC) defibrillators, the kind provided by batteries. In 1966, J. Frank Pantridge and John Geddes developed the world’s first mobile intensive care unit (MICU) in Belfast, Northern Ireland, as a way to bring early advanced medical care to patients with cardiac emergencies (3). In 1969, William Grace established the first MICU in the United States in New York City (4). Subsequently, there were efforts in the United States and throughout the world to emulate and build on this concept. In the late 1960s and early 1970s, paramedic programs were developed by Eugene Nagel in Miami, Leonard Cobb in Seattle, Leonard Rose in Portland, Michael Criley in Los Angeles, and James Warren and Richard Lewis in Columbus. In the 1980s, Mickey Eisenberg, Richard Cummins, From: Contemporary Cardiology: Cardiopulmonary Resuscitation Edited by: J. P. Ornato and M. A. Peberdy © Humana Press Inc., Totowa, NJ 229 230 Cardiopulmonary Resuscitation and colleagues demonstrated the effectiveness of rapid defibrillation in Seattle, Wash- ington (5), while Kenneth Stults demonstrated the same in rural Iowa (6). This growing body of research demonstrated the importance of rapid care for victims of sudden CA by showing that survival improved when basic life support (mouth-to-mouth ventilation and closed chest compressions) was provided within 4 minutes and advanced life support (defibrillation, intravenous medications and fluids, and advanced airway management) within 8 minutes. Subsequent studies found that the benefits of advanced life support were primarily the result of electrical countershock for patients in ventricular fibrillation (VF). From these findings, a model of care called the “Chain of Survival,” was first described by Mary Newman (7), and then by Cummins et al. (8), and eventually adopted by the Citizen CPR Foundation, the American Heart Association (AHA) and others. The Chain of Survival consists of four action steps that must occur in rapid succession to provide the patient the greatest likelihood for resuscitation: early access (call 911 or the local emergency number to notify the emergency medical services [EMS] system and summon on-site help); early cardiopulmonary resuscitation (CPR; begin immediately); early defibrillation; and early advanced care (transfer care to EMS professionals upon their arrival at the scene).

THE CHALLENGE OF PROVIDING EARLY DEFIBRILLATION Growing appreciation of the value of early defibrillation prior to hospital arrival and of the need for improved care of trauma victims led to the development of EMS systems in most nonrural communities throughout the United States. Through the efforts of dedicated individuals who underwent training as emergency medical technicians and paramedics, along with government funding of well-equipped ambulances designed specifically for providing emergency medical care outside the hospital, great strides were made in improving the initial care provided to persons with out-of-hospital emergencies. Despite these advances, decades later, the death toll from sudden CA remains as high as 98 to 99% (9,10), with a national average of 93% (11). The reason for the dismal survival rate from sudden CA became profoundly evident— time to intervention. Although the development of EMS systems is perhaps one of the greatest improvements in US health care this century, expecting such systems to effectively treat victims of sudden CA within our current medical understanding and the limitations of EMS response intervals clearly is fallacious. Spaite et al. developed a useful description of the time intervals between patient collapse and provision of care (Fig. 1; [12]). There have been many efforts made to shorten each of these time intervals. Addi- tionally, significant advances in each phase of out-of-hospital emergency response have lead to significant improvements over the years. There is clearly a limit, however, to minimizing response-time intervals. Even small improvements in survival come at a high price. Nichol et al. demonstrated that an improvement in response time of 48 seconds would cost an estimated $40,000 to $368,000 per quality adjusted life year gained depen- dent on system configuration (13). Thus, traditional EMS systems should not be expected to provide the first few minutes of emergency cardiovascular care, because it often is not deliverable at a reasonable cost.

AUTOMATED EXTERNAL DEFIBRILLATORS Fortunately, medical technology has now provided a solution to this dilemma. The advent of automated external defibrillators (AEDs) now allows persons with very little Chapter 13 / Public Access Defibrillation 231

Fig. 1. Emergency medical services time-interval model.

training and no formal medical background to provide the lifesaving intervention of early defibrillation. AEDs are essential weapons in the current battle against sudden CA, and so a brief review of their characteristics is in order. The key components of an AED are as follow: • computer to perform ECG analysis, • battery, • capacitor, • defibrillation pads and connector cable, and • external shell with control buttons. Although each manufacturer’s device varies slightly, they are relatively consistent in their operation. Turning the device on typically initiates a series of verbal instructions. The device prompts the user to attach the defibrillation pads to the patient’s chest. By detecting a change in impedance, the AED knows when the pads have been attached. (In devices in which the pads are not pre-attached, the device will prompt the user to attach the connector cable to the AED.) Once the pads are placed on the chest, the device initiates an electrocardiogram (ECG) analysis, typically evaluating two short segments of ECG strip for morphology, rate, and nonphysiologic signals (artifact and interference). If analysis of both of these segments agrees that a shock is indicated, the device charges the capacitor and advises the user of the finding. When the capacitor is charged, the device prompts the user to push the “shock” button. Some devices currently on the market will warn the user to “clear” the patient, that is, make sure no one is touching the patient, and then automatically deliver the shock, without requiring the user to push any buttons. The AED automatically initiates reanalysis after a shock to determine if another shock is needed; it will repeat this process for up to three consecutive shocks. After a third consecutive shock, the device will withhold analysis for 1 minute and prompt the user to do CPR during that interval. In all cases, users are guided by voice prompts that transfer decision making from the user to the computerized device. 232 Cardiopulmonary Resuscitation

The algorithms used to define shockable rhythms in AEDs have been continually refined over the last 20 years and are now quite sophisticated and accurate. Several evaluations have found their specificity to be close to 100%, which means that the device will not shock ECG rhythms that would not be shocked by an advanced care provider performing manual defibrillation. The sensitivity typically is 90 to 95% with most “misses” being very fine VF (14,15). Multiple models of AEDs are now available and new ones are entering the market on a regular basis (Fig. 2). They include both new brands and upgraded models of existing brands. To see the current models on the market, visit the National Center for Early Defibrillation website (www.early-defib.org) (16). A variety of AED improvements have been proposed recently. One concern is the need to shorten the “hands-off interval,” during which chest compressions are withheld (17).This interval consists of listening to prompts, applying defibrillation pads, AED rhythm analysis, capacitor charging, and shock delivery and typically takes 60 to 90 seconds, even for proficient users. Another consideration is whether or not AEDs should incorporate communication capabilities to automatically alert the local 911 center when and where a device is activated and/or allow the telecommunication officer to speak with the user directly. Both options add additional cost, size, and weight to the device. Thus, the dilemma is whether it is better to have the smallest, most portable, lowest priced devices or to ensure rapid 911 notification and real-time user assistance. A lower priced device could mean wider distribution of AEDs and hopefully more rapid availability of a device, whereas an automatic connection would assist users in proper use of the device and care for the individual and the additional benefit of ensuring immediate dispatch of EMS. An intriguing potential development is the incorporation of defibrillation success prediction guidance. Callaway has demonstrated the ability of the scaling exponent, a measure of the VF tracing’s geometric characteristics, to predict likelihood of conversion to an organized rhythm (18). Others are evaluating the utility of frequency and amplitude- based analyses (19). The clinical relevance is that the AED could base the decision to shock not just on the presence of VF but also on the likelihood of successful conversion. For patients with low likelihood of conversion, basic and advanced life support could be provided prior to defibrillation. The most optimal defibrillation waveform remains unknown. Most new devices on the market use biphasic waveforms rather than the previous standard, monophasic waveform. The biphasic waveform at a lower energy level seems to be at least as effective as the higher energy monophasic and thus can decrease the size, weight, and cost of the device. Whether a low-energy biphasic waveform or an escalating biphasic waveform is more effective remains to be determined. In summary, AEDs have become very simple and easy to use. A minimal amount of training is required to become familiar with the device In fact, a study comparing untrained, sixth-grade children and EMTs in the use of an AED illustrates just how easy these devices are to use: untrained children were able to operate the AED successfully in a time that was only 27 seconds longer than it took the EMTs to use the device (20).

STRATEGIES FOR EARLY DEFIBRILLATION Today, the best known strategy for resuscitating persons in sudden CA is to provide defibrillation as soon as possible for those in ventricular tachycardia (VT) and VF, Chapter 13 / Public Access Defibrillation 233

Fig. 2. Some automated external defibrillator models currently available. Courtesy of the National Center for Early Defibrillation, University of Pittsburg (www.early-defib.org). (A) AccessAED (Access CardioSystems); (B) Samaritan® AED (HeartSine Technologies Inc.); (C) LIFEPAK CRPlus (Medtronic Physiocontrol Corp.); (D) Fr2+ (Philips Medical Systems); (E) AED 10 (Welch Allyn Inc.); (F) AED Plus (Zoll Medical Corp.). 234 Cardiopulmonary Resuscitation perform closed chest compressions, and provide ventilation and oxygenation. Because victims in VF and VT have a much higher likelihood of survival than those with other rhythms, reaching these victims and delivering defibrillation has been emphasized. AEDs have provided an important means to achieve this goal. The earliest clinical report of these devices is from Bellingham, Washington, by Diack and Wayne et al. in 1979 (21). The device was designed to conduct current between a combination oral airway/metallic electrode in the orophanynx and an electrode on the mid-anterior chest. The device underwent further development and modi- fications including the transition to more traditional electrode placement on the left and right anterior chest. Soon thereafter, Cummins, Stults and others demonstrated safe and effective use of these devices by Emergency Medical Technicians (7,22). In 1989, Weaver reported that equipping firefighter/first responders in King County, Washington with these devices would achieve a calculated survival improvement among patients in VF from 19 to 30% (23). This report provided not only legitimacy to the new technology, but also a call for their deployment among first responders throughout the country. Although paid firefighters became first responders in many urban areas, this resource was not available in many suburban communities. In these locations, police officers were often the most likely first responders. White et al. in 1996 (24), and Mosesso et al. in 1998 (25), published reports demonstrating successful use of AEDs by police officers. White found a heretofore never reported survival rate of 45% with roughly similar survival whether shock was provided by EMS or police officers in Rochester, Minnesota. Mosesso’s study in a suburban area near Pittsburgh, Pennsylvania, demonstrated a marked improvement in survival if police attempted to defibrillate sudden CA victims upon their arrival rather than waiting for EMS personnel (survival to hospital discharge 26 vs 3%, p = 0.027). Davis et al. reported that police officers in the Pittsburgh study were able to use the device effectively with minimal errors (26). These studies also demonstrated the devices were safe and rarely malfunctioned. The evolution of excellent 911 centers and of emergency medical dispatch (i.e., pri- oritized dispatch and pre-arrival instructions) has also facilitated more rapid deployment to CA calls. Despite these advances, however, first responders and EMS personnel generally are unable to reach the scene and provide therapy within the very small window of opportunity afforded to victims of sudden CA. Therefore, it has been increasingly recognized that the only way to effectively provide what might be called “immediate defibrillation” is to have the defibrillator on site and accessible to the lay bystander. Air travel is one venue in which the need for immediate defibrillation is overt and which the AED strategy has proven success. The nature of this venue creates an exceptionally long time interval before traditional EMS is able to respond. Therefore, Qantas Airlines took what at the time was a bold step to equip nonmedical personnel, such as flight attendants, with AEDs (27). Subsequently, Richard Page reported the American Airline experience (28). During a 2-year period, 200 (191 on aircraft and 9 in terminal) arrests occurred. The Federal Aviation Administration (FAA) has now mandated that all airlines with at least one flight attendant be equipped with an AED and that the staff had to be trained in their use. Determination of other appropriate venues for AEDs is still unfolding. Perhaps the largest effort to address this question is the Public Access Defibrillation (PAD) Trial (29), which is comparing survival at sites with teams trained in CPR only vs sites with teams trained in CPR and AED use and equipped with AEDs. The trial found survival doubled at sites with AEDs and that no patients were shocked inappropriately (29a). Researchers Chapter 13 / Public Access Defibrillation 235 also hope to learn important information about effective response plan strategies and retraining requirements. The PAD Trial chose locations that would have a reasonable likelihood of CA by using the criterion of at least 250 people over age 50 present at the site for 16 hours a day or 500 persons present for 8 hours per day. Response plans were designed to initiate CPR immediately and apply the defibrillator within 3 minutes of the individual’s collapse. Several studies have tracked the incidence of sudden CA by type of location. Linda Becker found in Seattle that CA occurred most frequently at the airport, county jail, large shopping malls, public sports venues, and large industrial sites. They developed a criterion of greater than 0.03 arrests per year for “high-risk” locations and found that sites that met this criterion could be expected to use each AED once every 10 years (30). At sites that did not meet these criteria, the defibrillator would be used rarely, and thus the authors question the appropriateness of employing AEDs in those locations. Frank et al. evaluated CA in Pittsburgh and found that no single location had a particularly high incidence. The most common venues at which CA occurred were dialysis centers and nursing homes (31). Although the concept of deploying AEDs at various public locations is just beginning to unfold, there are already questions being raised regarding the potential impact of such a strategy. This is because 57 to 75% (32,33) of CAs occur in private residences. Thus, only one-quarter to one-third of CAs can even be treated by a public access defibrillation strategy. Several studies have calculated that public access defibrillation programs, even if they achieve a high survival rate, will have only minimal impact on the overall survival in communities (34). This has led some to suggest that the ultimate venue for on-site defibrillators may be the home. The concept raises a number of issues including how often arrests at home are witnessed, the feasibility of family members using the AED in the crisis situation and the cost of placing AEDs in every home (35). A study exploring these issues is the Home Access Defibrillation Trial by researchers at the University of Washington. Nevertheless, a number of successful programs and models providing on-site defibrillation have been reported and a number of important program components have been identified. EARLY DEFIBRILLATION PROGRAMS AND MODELS There are a variety of different models and systems for on-site defibrillation programs. We endorse the concept that the deployment of AEDs should involve, in most cases, implementation of an emergency response plan. This is especially true in locations where there is some identifiable fixed population such as a security force or office work force. In systems with on-site security officers who can quickly respond to the location of an emergency, it is often appropriate to train and equip these officers with the AEDs. Other settings may have a steady workforce such as managers, clerks, or office workers but not a designated security response force. In these instances, it may be feasible to either assign a certain group or solicit a volunteer group to receive training and to respond to medical emergencies. Often it is appropriate to deploy AEDs in such a fashion that they are available for anyone at the site to use. The Chicago airport model reported by Caffrey et al. may best exemplify this model (36).AEDs were placed within a brisk 60- to 90-second walk apart in the Chicago O’Hare, Meigs Field, and Midway Airports. The cabinets were designed to trigger an audible alarm, strobe lights, and a dispatcher alert if the cabinet door was opened. The three airports serve more than 100 million passengers each year and employ a staff of 44,000. Of this pool of employees, 236 Cardiopulmonary Resuscitation

3000 were trained; users of the airports were alerted to the fact that AEDs were available in multiple ways: public service videos that repeatedly played in the waiting areas, pamphlets, and news media. In the initial 2 years of the study, 21 persons experienced nontraumatic CA; 18 out of the 21 cases were in VF. Eleven of the 18 (a remarkable 61%) survived. In five of these cases, persons who had no training or experience in the use of AEDs and no official duty to respond used the AED. This study suggests that there is benefit in making AEDs available to the general public. When designing response plans, the goal is to provide access to defibrillation as quickly as possible. All aspects of the program should be designed to facilitate this goal. How this is achieved often is based on site-specific issues, but should include the components described in the next section, which is based in large part on a comprehensive guide by Newman and Christenson (37).

ESTABLISHING A COMMUNITY-BASED AED PROGRAM An AED program can be considered a community initiative to promote public access to defibrillation. It may involve a consortium of any combination of community leaders, emergency medical services, local chapters of national organizations dedicated to this issue, and civic groups. This program may include ensuring that public safety-first responders are trained and equipped in the use of AEDs and promoting deployment in public venues throughout the community. Based on programs that have been published in the literature, and through personal communications with many leaders of such community programs, we have found that addressing the following 10 components will often facilitate the development of a successful and effective program. Establish an AED Task Force Strong community AED programs often begin with a single champion who is able to mobilize community support and buy-in. To be most effective, it helps to gather all potential stakeholders up front and form a task force. At a community level, this means people like the EMS director, fire chief or training officer, police chief or training officer, corporate leaders, elected officials, and representatives of training organizations, civic groups, senior citizens organizations, and the media. Review Laws, Regulations, and Advisories AED use is addressed in several federal laws and advisories, state laws, and sometimes even in local ordinances. All AEDs on the market in the United States have been cleared by the Food and Drug Administration (FDA), which means they have been determined to be safe and effective. The FDA requires a prescription for the purchase of an AED. All states now have Good Samaritan AED legislation. In general, these laws provide immunity from legal liability for those who use and deploy AEDs, but the details vary from state to state. Some states require training by nationally recognized training organizations, coordination with EMS, medical direction, and record keeping. The federal CA Survival Act, which addresses AED placement in federal building, also fills in the gaps in state Good Samaritan legislation, providing an additional measure of immunity. Other actions at a federal level that support AED deployment are the FAA ruling that requires AEDs on airlines, the Occupational Safety and Health Administration advisory that recommends AEDs at the workplace and the General Accounting Office report that addresses CA data collection. Chapter 13 / Public Access Defibrillation 237

Conduct a Needs Assessment Evaluate the strength of each link in the chain of survival to enable strategic improvements in the response system. Determine the highest risk sites for sudden CA and identify locations that may have delayed response by public safety and/or EMS (including delayed access to patient once on site). Cultivate Public Awareness Strong community AED programs depend on public awareness and involvement. The task force needs to develop a public awareness campaign, particularly if funding will be needed to support the program. This involves framing the issues, developing a statement of need, promoting media coverage, lobbying local political leaders, and identifying and addressing potential obstacles. Estimate Program Costs Establishing an effective community AED program involves not only the cost of devices, but other issues including initial and refresher training, medical direction, personnel related to program management and quality assurance, maintenance, documen- tation, media coverage, and community-wide CPR training. Before seeking funding, task forces should understand start-up and maintenance costs. Seek Funding Sometimes the costs of AED programs are incorporated into agency budgets. In many cases, however, outside funding is needed. There are many sources for AED program funding. Organizations and individuals will be more likely to contribute if your task force either forms a nonprofit 501(c)3 organization or aligns with one, so that contributions are tax deductible. For funding sources, see www.early-defib.org. Establish Medical Oversight Medical oversight for AED programs is required in some states. It is recommended by numerous national medical organizations, including the National Center for Early Defibrillation and the American Heart Association. The role of the medical director is to champion the program in the community, prescribe devices, and ensure quality. This involves developing or approving protocols, overseeing training, reviewing cases, providing feedback to rescuers and conducting data analysis. Select Device Many AED models are on the market. Some issues to consider include ease of use, compatibility with other devices in use in the service area, maintenance, ongoing manufacturer support, appropriateness for specific venue and expected users, and price. For device options, see www.early-defib.org. Conduct Training AED training generally takes about 2 to 4 hours, including CPR training. Refresher training should be conducted periodically and is available through on-line programs. Many experienced AED program coordinators recommend brief (i.e., as little as 10 minutes) refresher training every 3 months. Several organizations provide nationally recognized quality programs in CPR and AED use. For training options, see www.early-defib.org. 238 Cardiopulmonary Resuscitation

Develop a Response Plan To ensure that every person receives optimal care as quickly as possible, it’s essential to develop a comprehensive, well-designed response plan. An effective plan consists of written policies and procedures developed with and reviewed by the medical director on a regular basis. The response plan should address the following: • Identification and training of the response team • Specific roles of team members • AED placement (location, installation, ancillary supplies) • Internal and external (911) notification systems • Response system function • Periodic AED drills • Postevent review and feedback Example of Community AED Program: Montgomery County, Texas Montgomery County Hospital District (MCHD) came to the conclusion that combating CA was not something that their ambulance service could do alone. Spanning 1100 square miles of urban, suburban, and rural areas, this Texas county with a population of 300,000, faced a number of obstacles. In the rural areas, the long distances that the MICUs needed to cover to reach a patient made achieving rapid response times difficult. In the urban areas, on the other hand, MICUs were able to arrive on scene quickly, locating the patient in a large building or crowd often created a substantial delay. In either case, achieving the 3- to 5-minute response interval needed for effective defibrillation of patients in CA was not possible using only the MICU system. MCHD contemplated methods outside the MICU system to expedite access to defibrillation for victims of out-of-hospital CA. With this objective in mind, it designed a comprehensive first-response AED program that could be implemented in three stages over a 3-year period. The first stage was a Fire Department First Response program. MCHD purchased 30 AEDs for distribution among the 17 county fire departments. Additionally, MCHD offered firefighters free EMT or Emergency Care Attendants training. Later, MCHD created a special CPR/AED training course that included instruction in post- resuscitation care for patients who were resuscitated successfully, and lessons in what to do when a shock is not advised. More than 300 firefighters participated in the training courses. Overall, the Fire Department First Response program was a great success and recorded its first save in the first month of the program. The second stage of the AED program was Law Enforcement First Response. MCHD invited the Shenandoah Police Department and the Montgomery County Sheriff’s Department to join the AED team. MCHD provided the initial training and 36 AEDs for their use. The third stage of the AED program was Community Access Defibrillation. MCHD focused on placing AEDs in locations where large populations of people congregate: malls, county buildings, schools and golf courses. Through local presentations on the importance of AEDs and the media coverage that they received, several community associations learned about the MCHD initiative and sought to partner with them and create AED programs in their area. MCHD consulted with each group to help them design a customized AED program that would offer the fastest and most effective response to an emergency. In most of these sites, MCHD targeted security personnel and maintenance staff as designated responders and provided them with free training. Interested Chapter 13 / Public Access Defibrillation 239 citizens were invited to also partake in training and many did so. The first community save was of a man in his mid-40s on the 11th fairway during a golf tournament. Responders on bikes arrived with the AED and defibrillated successfully. All three stages of the AED program initiated by MCHD were met with great enthu- siasm by the media, public, and participators, alike. Even groups that were long-standing political adversaries of MCHD supported the hospital and its use of funds for this effective, lifesaving initiative. Additional support came from a wide variety of sources including government agencies, homeowners associations, businesses, civic associations, and grants. To ensure continued quality management of the Montgomery County Hospital Pro- gram, all participants in the program follow the single protocol designed by the EMS medical director. A full-time program coordinator was hired to oversee deployment of AEDs and the initial and ongoing training activities for 450 lay responders and 15 community sites. A total of 134 AEDs have been deployed within Montgomery County. The success of the program is illustrated clearly in the 28 pictures of survivors that hang on the MDHD Wall of Fame.

ESTABLISHING AN ON-SITE AED PROGRAM The 10 principles for establishing a community AED program can be applied and expanded for on-site AED programs, as follows. Establish Program Leadership A program coordinator, a specific individual who is empowered to lead this effort, shold be named. This individual should have backing at the highest level of the corpo- ration or organization and should be authorized to use resources and personnel as neces- sary to implement an effective program. A medical advisor should be selected and involved in the overall planning of the program from its inception. This will ensure that the primary principles of rapid response and appropriate medical interventions by various personnel are addressed. Review Laws and Regulations Determine any specific laws that might impact on deployment of the AEDs, including any need for registration with state or local government or EMS. Consider whether any requirements are imposed for the protection through Good Samaritan Laws. Consider any regulations that might affect the installation of devices, such as location for wall mounting and signage. Site Assessment The goal should be that a responder and the AED arrive at the individual’s side within 3 minutes of system activation. Thus, site assessment must evaluate time to respond to various locations at the site and potential obstructions, such as entries with restricted access that might delay response. Occupancy and visitation rates also should be evaluated. Develop Response Plan A written response plan should be designed to ensure the most rapid response feasible during all hours of operation. The response plan should be developed in collaboration 240 Cardiopulmonary Resuscitation with the medical advisor and approved by top management. It should address the following components: • Identification and training of the response team • Specific roles of team members • AED placement • Internal and external (911) notification systems • Response system function during operational hours • Periodic AED drills • Postevent review and feedback. Develop a Program Budget This should include the cost of the device, ancillary equipment for the device (this could include an extra set of pads, spare batteries, pocket mask, or other barrier device for mouth-to-mouth ventilation, protective gloves, scissors), training costs, medical consultation, general awareness and education for all site occupants, signage, and installation. Select Device There are a variety of different AED brands and models on the market. The various models should be evaluated for a good fit in a particular setting based on site-specific issues including storage conditions and personnel who will be using the device. For device options, see www.early-defib.org. Conduct Training Personnel designated to respond should receive formal training in both basic CPR and use of the AED. This generally can be accomplished in 3 to 4 hours of training initially with retraining conducted in a very brief fashion every 3 to 6 months. Formal retraining is recommended every 2 years. There are a number of organizations that provide nationally recognized quality programs in CPR and AED use. Additionally, there are also private companies that provide training. (For information, see www.early-defib.org.) If resources allow, one should consider opening training to all occupants of a site even if they are not part of the formal response team. Device Installation Device placement depends on the response plan. If the plan provides for delivery of the AED by designated individuals, such as a security team, then deployment should enable these personnel to have immediate and direct access to the device at all times. Whenever possible, devices should be deployed in such a way that they are also readily accessible to other occupants and visitors to the building to increase the likelihood of timely use. There are a number of brackets and enclosed cases designed for wall mounting of devices. These can be armed with alarms, both audible and visual, and can be con- nected to either an on-site communication center or the local 911 call center. Signage indicating the location of the device should be installed to enable it to be visible down hallways from a distance. The NCED suggests using a standard symbol for AEDs (Fig. 3). Awareness and Education All building occupants, and in appropriate settings, visitors, should be informed of the emergency response program and all occupants should be educated on how to activate the Chapter 13 / Public Access Defibrillation 241

Fig. 3. Symbol for AEDs promoted by The National Center for Early Defibrillation.

response plan. One such strategy is to place signage and pamphlets at entryways and lobbies of buildings on the availability of AEDs and how to activate the on-site response team when applicable. Continuous Evaluation The on-site AED program should be assessed on a regular basis to ensure its effectiveness, especially the timeliness of response. After every event, the program coordinator and medical consultant should evaluate individual responses and use of the AED. Feed- back should be provided both to individuals and to the entire response team. Regular reminders about when and how to activate the response team should be provided to all building occupants. Example of Worksite AED Program: The Hillman Company Two encounters with sudden CA brought the importance of immediate access to defibrillation to the attention of the employees at the Hillman Company. Soon after, the company decided to implement an AED program in their office in Pittsburgh, Pennsyl- vania. An employee in Human Resources was selected to serve as the primary in-house AED program coordinator. The company also contracted with a medical director and AED program support specialist to assist them in designing an effective program that would ensure the best possible response to an emergency. Creating such a response system involved several components. Placement of the AED was the first. Based on the AHA recommendations to provide defibrillation within 3 to 5 minutes of collapse, it was determined that the Hillman Company would need an AED on each floor of the building they occupy. The AEDs were placed in high-traffic areas, and supplied with ancillary items such as a razor, towel, CPR pocket mask, scissors, and alcohol wipes. All employees were alerted regarding the location of the devices. The next order of business was determining who would be trained to use the AED. The Hillman Company already had a group of employees, called “fire marshals,” that had 242 Cardiopulmonary Resuscitation volunteered to lead an evacuation of the building in the case of fire. The duties of the fire marshals were expanded to lead in the use of an emergency response involving the AED and their title was changed to emergency response marshals. This group, along with some additional volunteers, was trained in CPR and AED through the AHA Heartsaver AED course. They have been recertified every 2 years and receive shorter refresher training every 6 months. The Hillman security system is used to activate the on-site response plan. Security buttons existed throughout the company under desks and near phones. Pressing one of these buttons alerts the guard at the front lobby security desk when and where an emergency occurs. The guard, in turn, calls 911, retrieves an elevator and guides the emergency medical technicians to the patient. After hours when no guard is on duty, the marshal places the call directly to 911. If alone, he or she can use a speed dial number to activate the public announcement broadcasting system and call any employee in the building to come and help. All the components of the AED program are contained in a comprehensive policies and procedures manual. The manual includes information such as the placement of the AEDs; the names of the emergency response marshals; the procedures for calling for help; an explanation of how to perform CPR and use the AED that they had purchased for the company; checklists for the maintenance of the device, procedures for the reporting any event involving the AED to the medical director; and answers to frequently asked questions about AEDs. The program was registered with the State of Pennsylvania’s Emergency Medical Services Institute, and coordinated with the local ambulance service to help ensure seam- less transfer of care. It was established that if the AED is ever used, the medical director will be contacted within 24 hours to review the response, together with the data stored in the AED, for the purpose of quality improvement. Although tested in a successful mock drill, the program has, fortunately, not been put to the test in a real situation. Hillman Company employees can rest assured, however, that if a CA event does occur, the on-site emergency response plan should ensure rapid and effective treatment.

SUMMARY Although sudden CA remains a leading cause of death in the Western world, the advent of AEDs is allowing a new assault on this stealth, silent killer. These devices allow lay bystanders and nonmedical emergency responders to provide defibrillation—the only known effective therapy for VF. AEDs are safe and effective, easy to use and difficult to misuse, require low maintenance, and are becoming less costly. A growing number of communities and specific venues have reported successful early defibrillation programs. Public access defibrillation is a critical component of the optimal intervention strategy for combating sudden CA. A Short History of Modern Resuscitation 1904: George Crile performs first American case of closed-chest cardiac massage. 1933: William Kouwenhoven et al. publish study on initiation and erasure of VF with electric shocks 1946: James Elam performed mouth-to-nose ventilation on polio patients 1947: Claude Beck successfully defibrillates 14-year-old boy using open-chest massage and AC defibrillator Chapter 13 / Public Access Defibrillation 243

1951: Archer Gordon publishes study on superiority of Nielson’s back-pressure arm-life method. 1954: Elam publishes study on effectiveness of exhaled air for artificial ventilation 1956: Paul Zoll demonstrates effectiveness of closed-chest defibrillation using AC defibrillators. 1956–1957: Peter Safar demonstrates effectiveness of mouth-to-mouth ventilation in adults. 1957: Archer Gordon demonstrates effectiveness of mouth-to-mouth ventilation in infants and children. 1960: First prehospital CA patient saved with CPR and defibrillation in ED 1960: William Kouwenhoven, James Jude and Guy Knickerbocker publish study demonstrating effectiveness of closed-chest cardiac compression. 1960: Safar, Kouwenhoven and Jude combine mouth-to-mouth ventilation with chest compression to create modern CPR. 1961–1962: Bernard Lown demonstrates superiority of DC over AC defibrillation. 1966–1967: J. Frank Pantridge and John Geddes establish world’s first mobile intensive care unit and publish findings. 1969: William Grace establishes first MICU in United States (in New York City) 1969–1970: Eugene Nagel in Miami, Leonard Cobb in Seattle, Leonard Rose in Portland, Michael Criley in Los Angeles, James Warren and Richard Lewis in Colum- bus establish first paramedic programs. 1972: Leonard Cobb begins to train 100,000 citizens in CPR in Seattle (1)

ACKNOWLEDGMENTS The authors would like to thank Chrysia Melnyk for her superb assistance with the preparation of this manuscript.

REFERENCES 1. Eisenberg M. Life in the Balance. Oxford: Oxford University Press, 1997. 2. Page JP. The Paramedics. Morristown, NJ: Backdraft Publications, 1979. 3. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction. Lancet 1967; 2:271. 4. Grace WJ, Chadborn JA. The mobile coronary care unit. Diseases of the Chest 1969; 55:452–455. 5. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance or rapid provision and implications for program planning. JAMA 1979; 241:1905–1907. 6. Stults KR, Brown DD, Schug VL, et al. Prehospital defibrillation performed by emergency medical technicians in rural communities. N Engl J Med, 1984; 310:219–223. 7. Newman M. Chain of Survival takes hold. JEMS 1989; 14(8):11–13. 8. Cummins RO. Ornato JP. Thies WH. Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991; 83:1832–1847. 9. Lombardi G, Gallagher J, Gennis P. Outcome of out-of-hospital cardiac arrest in New York City: The Prehospital Arrest Survival Evaluation (PHASE) study. JAMA 1994; 271:678–683. 10. Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area – where are the survivors? Ann Emerg Med 1991; 20:355–361. 11. Callaway CW. Improving neurologic outcomes after out-of-hospital cardiac arrest. Prehosp Emerg Care 1997; 1:45–47. 12. Spaite DW, Valuenzuela TD, Meislin HW, Criss EA, Hinsberg P. Prospective validation of a new model for evaluating emergency medical services systems by infield observation of specific time intervals in prehospital care. Ann Emerg Med 1993; 22:638–645. 244 Cardiopulmonary Resuscitation

13. Nichol G, Laupacis A, Stiell IG, et al. Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest. Ann Emerg Med 1996; 27:711–720. 14. Herlitz J, Bang A, Axelsson A, Graves JR, Lindqvist J. Experience with the use of automated external defibrillators in out of hospital cardiac arrest. Resuscitation 1998; 37:3–7. 15. Macdonald RD, Swanson JM, Mottley JL, Weinstein C. Performance and error analysis of automated external defibrillator use in the out-of-hospital setting. Ann Emerg Med 2001; 38:262–267. 16. National Center for Early Defibrillation, University of Pittsburgh, Pennsylvania. http://www.early- defib.org 17. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation 2002; 106:368–72. 18. Callaway CW, Sherman LD, Mosesso VN, Jr., Dietrich TJ, Holt E, Clarkson MC. Scaling exponent predicts defibrillation success for out-of-hospital ventricular fibrillation cardiac arrest. Circulation 2001; 103:1656–1661. 19. Jekova I, Deshanova J, Popivanov D. Method for ventricular fibrillation detectin in the external electrocardiogram using nonlinear prediction. Physiol Meas 2002; 23:337–45. 20. Gundry JW, Comess KA, DeRook FA, Jorgenson D, Bardy GH. Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999; 100:1703–1707. 21. Diack AW, Welborn WS, Rullman RG, Walter CW, Wayne MA. An automatic ardiac resuscitator for emergency treatment of cardiac arrest. Medical Instrumentation 1979; 13:78–83. 22. Cummins RO, Eisenberg MS, Litwin PE, Graves JR, Hearne TR, Hallstrom AP. Automatic external defibrillators used by emergency medical technicians; a controlled clinical trial. JAMA 1987; 257: 1605–1610. 23. Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. New Engl J Med 1988; 319:661–666. 24. White RD, Aspin BR, Bugiosi TF, Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996; 28:480–485. 25. Mosesso VN, Davis EA, Auble TE, Paris PM, Yealy DM. Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med 1998; 32:200–207. 26. Davis EA, Mosesso VN. Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest. Preshosp Emerg Care 1998; 2:101–107. 27. O’Rourke MF, Donaldson E. The first five years of the Qantas cardiac arrest program. J Am Coll Cardio 1997; 29:404. 28. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a US airline. N Engl J Med 2000; 343:1210–1216. 29. Public Access Defibrillation Trial Investigators. PAD Trial study design and rationale. Resuscitation 2003; 56: 135–147. 29a.Ornato JP, et al. The Public Access Defibrillation Trail. American Heart Association, Late-Breaking Clinical Trials Plenary Session VII, November 2003, Orlando, FL. 30. Becker L, Eisenberg M, Fahrenbruch C, Cobb L. Public locations of cardiac arrest: implications for public access defibrillation. Circulation 1998;97:2106–2109. 31. Frank RL, Rausch MA, Menegazzi JJ, Rickens M. The locations of nonresidential out-of-hospital cardiac arrests in the City of Pittsburgh over a three-year period: implications for automated external defibrillator placement. PEC 2001;5:247–251. 32. Cobb LA, Fahrenbruch CE, Walsh TR. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA 1999;281:1220–1222. 33. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO. Location of collapse and its effect on survival from cardiac arrest. Ann Emerg Med 1987;16:669–672. 34. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. BMJ 2002;325:515–520. 35. Newman MM, Mosesso VN, Paris PM. “AEDs in the home: a position statement from the National Center for Early Defibrillation”. National Center for Early Defibrillation website Accessed: January 2002. 36. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med 2002;347:1242–1247. 37. Newman MM, Christenson JM. Challenging sudden death: a community guide to help save lives. Carmel, IN: Catalyst Research and Communications, Inc., 1998.