Chapter 13 / Public Access Defibrillation



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

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


Thus. The reason for the dismal survival rate from sudden CA became profoundly evident— time to intervention. 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. medical technology has now provided a solution to this dilemma. and early advanced care (transfer care to EMS professionals upon their arrival at the scene). Additionally. 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. AUTOMATED EXTERNAL DEFIBRILLATORS Fortunately. Washington (5). Despite these advances.000 to $368. There have been many efforts made to shorten each of these time intervals.000 per quality adjusted life year gained dependent on system configuration (13). developed a useful description of the time intervals between patient collapse and provision of care (Fig. a model of care called the “Chain of Survival. with a national average of 93% (11). early defibrillation. Nichol et al. significant advances in each phase of out-of-hospital emergency response have lead to significant improvements over the years.10). and then by Cummins et al. however. the American Heart Association (AHA) and others. great strides were made in improving the initial care provided to persons with out-of-hospital emergencies. decades later. because it often is not deliverable at a reasonable cost. while Kenneth Stults demonstrated the same in rural Iowa (6). the death toll from sudden CA remains as high as 98 to 99% (9. Spaite et al. 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). Although the development of EMS systems is perhaps one of the greatest improvements in US health care this century. The advent of automated external defibrillators (AEDs) now allows persons with very little . 1. traditional EMS systems should not be expected to provide the first few minutes of emergency cardiovascular care. There is clearly a limit. to minimizing response-time intervals. demonstrated that an improvement in response time of 48 seconds would cost an estimated $40. intravenous medications and fluids. along with government funding of well-equipped ambulances designed specifically for providing emergency medical care outside the hospital. Subsequent studies found that the benefits of advanced life support were primarily the result of electrical countershock for patients in ventricular fibrillation (VF). and advanced airway management) within 8 minutes. From these findings. and eventually adopted by the Citizen CPR Foundation.” was first described by Mary Newman (7). begin immediately). (8). 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.230 Cardiopulmonary Resuscitation and colleagues demonstrated the effectiveness of rapid defibrillation in Seattle. early cardiopulmonary resuscitation (CPR. Even small improvements in survival come at a high price. Through the efforts of dedicated individuals who underwent training as emergency medical technicians and paramedics. [12]).

the AED knows when the pads have been attached. that is. After a third consecutive shock. training and no formal medical background to provide the lifesaving intervention of early defibrillation. rate. and • external shell with control buttons. Turning the device on typically initiates a series of verbal instructions.) Once the pads are placed on the chest. If analysis of both of these segments agrees that a shock is indicated. typically evaluating two short segments of ECG strip for morphology. (In devices in which the pads are not pre-attached. • capacitor. and nonphysiologic signals (artifact and interference). the device will withhold analysis for 1 minute and prompt the user to do CPR during that interval. the device prompts the user to push the “shock” button. make sure no one is touching the patient. Some devices currently on the market will warn the user to “clear” the patient. The key components of an AED are as follow: • computer to perform ECG analysis. The device prompts the user to attach the defibrillation pads to the patient’s chest. 1. • battery. When the capacitor is charged. The AED automatically initiates reanalysis after a shock to determine if another shock is needed. AEDs are essential weapons in the current battle against sudden CA. it will repeat this process for up to three consecutive shocks. and so a brief review of their characteristics is in order. Although each manufacturer’s device varies slightly. users are guided by voice prompts that transfer decision making from the user to the computerized device. Emergency medical services time-interval model. • defibrillation pads and connector cable. . without requiring the user to push any buttons. In all cases.Chapter 13 / Public Access Defibrillation 231 Fig. the device initiates an electrocardiogram (ECG) analysis. they are relatively consistent in their operation. the device will prompt the user to attach the connector cable to the AED. the device charges the capacitor and advises the user of the finding. and then automatically deliver the shock. By detecting a change in impedance.

a study comparing untrained. STRATEGIES FOR EARLY DEFIBRILLATION Today. 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). 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. .15). and weight to the device. Whether a low-energy biphasic waveform or an escalating biphasic waveform is more effective remains to be determined. 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. Most new devices on the market use biphasic waveforms rather than the previous standard. The sensitivity typically is 90 to 95% with most “misses” being very fine VF (14. Thus. Several evaluations have found their specificity to be close to 100%. An intriguing potential development is the incorporation of defibrillation success prediction guidance. capacitor charging. and cost of the device. a measure of the VF tracing’s geometric characteristics. 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. 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. the dilemma is whether it is better to have the smallest. A variety of AED improvements have been proposed recently. most portable. Both options add additional cost. To see the current models on the market. In summary.This interval consists of listening to prompts. A lower priced device could mean wider distribution of AEDs and hopefully more rapid availability of a device. basic and advanced life support could be provided prior to defibrillation. visit the National Center for Early Defibrillation website (www. Multiple models of AEDs are now available and new ones are entering the market on a regular basis (Fig. and shock delivery and typically takes 60 to 90 seconds. 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.” during which chest compressions are withheld (17). to predict likelihood of conversion to an organized rhythm (18). monophasic waveform. A minimal amount of training is required to become familiar with the device In (16). For patients with low likelihood of conversion. size. even for proficient users. weight. 2). Others are evaluating the utility of frequency and amplitudebased analyses (19). AED rhythm analysis. lowest priced devices or to ensure rapid 911 notification and real-time user assistance. which means that the device will not shock ECG rhythms that would not be shocked by an advanced care provider performing manual defibrillation. They include both new brands and upgraded models of existing brands. AEDs have become very simple and easy to use.early-defib. applying defibrillation pads. The most optimal defibrillation waveform remains unknown.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. One concern is the need to shorten the “hands-off interval. Callaway has demonstrated the ability of the scaling exponent.

University of Pittsburg (www. (D) Fr2+ (Philips Medical Systems).org). (A) AccessAED (Access CardioSystems).). Courtesy of the National Center for Early Defibrillation. Some automated external defibrillator models currently available. .).Chapter 13 / Public Access Defibrillation 233 Fig.).). 2. (B) Samaritan® AED (HeartSine Technologies Inc. (F) AED Plus (Zoll Medical Corp. (E) AED 10 (Welch Allyn Inc.early-defib. (C) LIFEPAK CRPlus (Medtronic Physiocontrol Corp.

prioritized dispatch and pre-arrival instructions) has also facilitated more rapid deployment to CA calls. White et al. The trial found survival doubled at sites with AEDs and that no patients were shocked inappropriately (29a). The nature of this venue creates an exceptionally long time interval before traditional EMS is able to respond. 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. in 1979 (21). Minnesota. Davis et al. AEDs have provided an important means to achieve this goal. published reports demonstrating successful use of AEDs by police officers. Richard Page reported the American Airline experience (28). 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%. 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. 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. p = 0. with AEDs (27). such as flight attendants. and Mosesso et al.027). by Diack and Wayne et al. Although paid firefighters became first responders in many urban areas. The earliest clinical report of these devices is from Bellingham. and provide ventilation and oxygenation. reaching these victims and delivering defibrillation has been emphasized. Weaver reported that equipping firefighter/first responders in King County. Researchers . Cummins. 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. Subsequently.. Because victims in VF and VT have a much higher likelihood of survival than those with other rhythms. Soon thereafter. however. Determination of other appropriate venues for AEDs is still unfolding. Therefore. This report provided not only legitimacy to the new technology. in 1996 (24). in 1998 (25). Perhaps the largest effort to address this question is the Public Access Defibrillation (PAD) Trial (29). Therefore. Air travel is one venue in which the need for immediate defibrillation is overt and which the AED strategy has proven success. 200 (191 on aircraft and 9 in terminal) arrests occurred. Despite these advances. Mosesso’s study in a suburban area near Pittsburgh.22). In 1989. 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.e. The device underwent further development and modifications including the transition to more traditional electrode placement on the left and right anterior chest. this resource was not available in many suburban communities. Washington with these devices would achieve a calculated survival improvement among patients in VF from 19 to 30% (23). police officers were often the most likely first responders.234 Cardiopulmonary Resuscitation perform closed chest compressions. These studies also demonstrated the devices were safe and rarely malfunctioned. Qantas Airlines took what at the time was a bold step to equip nonmedical personnel. The evolution of excellent 911 centers and of emergency medical dispatch (i. 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. Stults and others demonstrated safe and effective use of these devices by Emergency Medical Technicians (7. During a 2-year period. Pennsylvania. In these locations. but also a call for their deployment among first responders throughout the country. Washington. reported that police officers in the Pittsburgh study were able to use the device effectively with minimal errors (26).

This has led some to suggest that the ultimate venue for on-site defibrillators may be the home. it is often appropriate to train and equip these officers with the AEDs. The Chicago airport model reported by Caffrey et al. and Midway Airports. and a dispatcher alert if the cabinet door was opened. EARLY DEFIBRILLATION PROGRAMS AND MODELS There are a variety of different models and systems for on-site defibrillation programs. and thus the authors question the appropriateness of employing AEDs in those locations. The most common venues at which CA occurred were dialysis centers and nursing homes (31). Response plans were designed to initiate CPR immediately and apply the defibrillator within 3 minutes of the individual’s collapse.Chapter 13 / Public Access Defibrillation 235 also hope to learn important information about effective response plan strategies and retraining requirements. county jail. and large industrial sites. Linda Becker found in Seattle that CA occurred most frequently at the airport. only one-quarter to one-third of CAs can even be treated by a public access defibrillation strategy. will have only minimal impact on the overall survival in communities (34). This is because 57 to 75% (32. implementation of an emergency response plan. Although the concept of deploying AEDs at various public locations is just beginning to unfold. clerks. 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). Frank et al. even if they achieve a high survival rate.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). AEDs were placed within a brisk 60. in most cases. Several studies have calculated that public access defibrillation programs. We endorse the concept that the deployment of AEDs should involve. A study exploring these issues is the Home Access Defibrillation Trial by researchers at the University of Washington. . The cabinets were designed to trigger an audible alarm. the defibrillator would be used rarely.000. there are already questions being raised regarding the potential impact of such a 90-second walk apart in the Chicago O’Hare. In systems with on-site security officers who can quickly respond to the location of an emergency. 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. They developed a criterion of greater than 0. At sites that did not meet these criteria. public sports venues.33) of CAs occur in private residences. large shopping malls. Several studies have tracked the incidence of sudden CA by type of location. Often it is appropriate to deploy AEDs in such a fashion that they are available for anyone at the site to use. evaluated CA in Pittsburgh and found that no single location had a particularly high incidence. it may be feasible to either assign a certain group or solicit a volunteer group to receive training and to respond to medical emergencies. strobe lights. or office workers but not a designated security response force. Nevertheless. Thus. This is especially true in locations where there is some identifiable fixed population such as a security force or office work force. Of this pool of employees. The three airports serve more than 100 million passengers each year and employ a staff of 44. Meigs Field. Other settings may have a steady workforce such as managers. In these instances. may best exemplify this model (36). a number of successful programs and models providing on-site defibrillation have been reported and a number of important program components have been identified.

corporate leaders. also fills in the gaps in state Good Samaritan legislation. Review Laws. emergency medical services. and the media.236 Cardiopulmonary Resuscitation 3000 were trained. which means they have been determined to be safe and effective. and through personal communications with many leaders of such community programs. When designing response plans. How this is achieved often is based on site-specific issues. providing an additional measure of immunity. This study suggests that there is benefit in making AEDs available to the general public. It may involve a consortium of any combination of community leaders. and Advisories AED use is addressed in several federal laws and advisories. To be most effective. Eleven of the 18 (a remarkable 61%) survived. Regulations. and representatives of training organizations. . ESTABLISHING A COMMUNITY-BASED AED PROGRAM An AED program can be considered a community initiative to promote public access to defibrillation. the goal is to provide access to defibrillation as quickly as possible. this means people like the EMS director. these laws provide immunity from legal liability for those who use and deploy AEDs. medical direction. In the initial 2 years of the study. pamphlets. and civic groups. but the details vary from state to state. persons who had no training or experience in the use of AEDs and no official duty to respond used the AED. In general. the Occupational Safety and Health Administration advisory that recommends AEDs at the workplace and the General Accounting Office report that addresses CA data collection. 21 persons experienced nontraumatic CA. and news media. Some states require training by nationally recognized training organizations. Other actions at a federal level that support AED deployment are the FAA ruling that requires AEDs on airlines. All AEDs on the market in the United States have been cleared by the Food and Drug Administration (FDA). 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. and record keeping. All states now have Good Samaritan AED legislation. The federal CA Survival Act. civic groups. which is based in large part on a comprehensive guide by Newman and Christenson (37). At a community level. which addresses AED placement in federal building. Based on programs that have been published in the literature. 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. The FDA requires a prescription for the purchase of an AED. 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. state laws. police chief or training officer. and sometimes even in local ordinances. In five of these cases. senior citizens organizations. elected officials. but should include the components described in the next section. coordination with EMS. All aspects of the program should be designed to facilitate this goal. fire chief or training officer. 18 out of the 21 cases were in VF. we have found that addressing the following 10 components will often facilitate the development of a successful and effective program. it helps to gather all potential stakeholders up front and form a task force. local chapters of national organizations dedicated to this issue.

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. documentation. Conduct Training AED training generally takes about 2 to 4 hours. It is recommended by numerous national medical organizations. 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. particularly if funding will be needed to support the program. lobbying local political leaders. Refresher training should be conducted periodically and is available through on-line programs. developing a statement of need. 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). There are many sources for AED program funding. as little as 10 minutes) refresher training every 3 months. overseeing training.. Establish Medical Oversight Medical oversight for AED programs is required in some states. compatibility with other devices in use in the service area. Select Device Many AED models are on the market. and price. media coverage. see www.early-defib. This involves framing the issues. promoting media coverage. Cultivate Public Awareness Strong community AED programs depend on public awareness and involvement. see www.early-defib. providing feedback to rescuers and conducting data analysis. ongoing manufacturer support. maintenance. however. including CPR training. and ensure quality. Many experienced AED program coordinators recommend brief (i.e. Seek Funding Sometimes the costs of AED programs are incorporated into agency budgets. so that contributions are tax deductible. This involves developing or approving protocols. .org. For funding sources. reviewing cases. For device Several organizations provide nationally recognized quality programs in CPR and AED use. and community-wide CPR training. see www. but other issues including initial and refresher training. and identifying and addressing potential obstacles. task forces should understand start-up and maintenance costs. In many cases. prescribe devices. maintenance. Before seeking funding. Some issues to consider include ease of use. including the National Center for Early Defibrillation and the American Heart Association. medical direction. The task force needs to develop a public awareness campaign. outside funding is Estimate Program Costs Establishing an effective community AED program involves not only the cost of devices. appropriateness for specific venue and expected users. For training options. The role of the medical director is to champion the program in the community. personnel related to program management and quality assurance.

schools and golf courses. MCHD provided the initial training and 36 AEDs for their use. Interested . MCHD targeted security personnel and maintenance staff as designated responders and provided them with free training. achieving the 3. installation.238 Cardiopulmonary Resuscitation Develop a Response Plan To ensure that every person receives optimal care as quickly as possible. MCHD focused on placing AEDs in locations where large populations of people congregate: malls. it’s essential to develop a comprehensive. Later. well-designed response plan. The second stage of the AED program was Law Enforcement First Response. 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. it designed a comprehensive first-response AED program that could be implemented in three stages over a 3-year period. MCHD contemplated methods outside the MICU system to expedite access to defibrillation for victims of out-of-hospital CA. MICUs were able to arrive on scene quickly. locating the patient in a large building or crowd often created a substantial delay. The response plan should address the following: • • • • • • • Identification and training of the response team Specific roles of team members AED placement (location. In most of these sites. MCHD invited the Shenandoah Police Department and the Montgomery County Sheriff’s Department to join the AED team. Spanning 1100 square miles of urban. MCHD created a special CPR/AED training course that included instruction in postresuscitation care for patients who were resuscitated successfully. Additionally. MCHD offered firefighters free EMT or Emergency Care Attendants training. several community associations learned about the MCHD initiative and sought to partner with them and create AED programs in their area. With this objective in mind. the long distances that the MICUs needed to cover to reach a patient made achieving rapid response times difficult. the Fire Department First Response program was a great success and recorded its first save in the first month of the program. faced a number of obstacles. Overall. More than 300 firefighters participated in the training courses. The third stage of the AED program was Community Access Defibrillation. In the rural areas. An effective plan consists of written policies and procedures developed with and reviewed by the medical director on a regular basis. 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. this Texas county with a population of 5-minute response interval needed for effective defibrillation of patients in CA was not possible using only the MICU system. Texas Montgomery County Hospital District (MCHD) came to the conclusion that combating CA was not something that their ambulance service could do alone. suburban. In either case. In the urban areas.000. MCHD purchased 30 AEDs for distribution among the 17 county fire departments. Through local presentations on the importance of AEDs and the media coverage that they received. and rural areas. The first stage was a Fire Department First Response program. county buildings. on the other hand. and lessons in what to do when a shock is not advised.

civic associations. 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. a specific individual who is empowered to lead this effort. Thus. homeowners associations. Additional support came from a wide variety of sources including government agencies. 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. Occupancy and visitation rates also should be evaluated. This individual should have backing at the highest level of the corporation or organization and should be authorized to use resources and personnel as necessary to implement an effective program. public. all participants in the program follow the single protocol designed by the EMS medical director. alike. The first community save was of a man in his mid-40s on the 11th fairway during a golf tournament. Develop Response Plan A written response plan should be designed to ensure the most rapid response feasible during all hours of operation. businesses. The response plan should be developed in collaboration . Site Assessment The goal should be that a responder and the AED arrive at the individual’s side within 3 minutes of system activation. The success of the program is illustrated clearly in the 28 pictures of survivors that hang on the MDHD Wall of Fame. Consider whether any requirements are imposed for the protection through Good Samaritan Laws. as follows. Establish Program Leadership A program coordinator. including any need for registration with state or local government or EMS. Consider any regulations that might affect the installation of devices. shold be named. Review Laws and Regulations Determine any specific laws that might impact on deployment of the AEDs. lifesaving initiative. A total of 134 AEDs have been deployed within Montgomery County. Even groups that were long-standing political adversaries of MCHD supported the hospital and its use of funds for this effective. To ensure continued quality management of the Montgomery County Hospital Program. and participators. All three stages of the AED program initiated by MCHD were met with great enthusiasm by the media. site assessment must evaluate time to respond to various locations at the site and potential obstructions. and grants. such as location for wall mounting and signage. 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.Chapter 13 / Public Access Defibrillation 239 citizens were invited to also partake in training and many did so. such as entries with restricted access that might delay response. Responders on bikes arrived with the AED and defibrillated successfully.

There are a number of organizations that provide nationally recognized quality programs in CPR and AED use. visitors. 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. Additionally.early-defib. 3).early-defib. For device options. see www. should be informed of the emergency response program and all occupants should be educated on how to activate the . or other barrier device for mouth-to-mouth ventilation. one should consider opening training to all occupants of a site even if they are not part of the formal response team. such as a security team. signage. The NCED suggests using a standard symbol for AEDs (Fig. then deployment should enable these personnel to have immediate and direct access to the device at all times. there are also private companies that provide training. Whenever possible. and in appropriate Select Device There are a variety of different AED brands and models on the market. medical consultation. and installation. see www. both audible and visual.240 Cardiopulmonary Resuscitation with the medical advisor and approved by top Device Installation Device placement depends on the response plan. Conduct Training Personnel designated to respond should receive formal training in both basic CPR and use of the AED. There are a number of brackets and enclosed cases designed for wall mounting of devices. ancillary equipment for the device (this could include an extra set of pads. (For information. If the plan provides for delivery of the AED by designated individuals. Signage indicating the location of the device should be installed to enable it to be visible down hallways from a distance. 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. These can be armed with alarms. 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. general awareness and education for all site occupants. and can be connected to either an on-site communication center or the local 911 call center. scissors). training costs. spare batteries. protective gloves.) If resources allow. Formal retraining is recommended every 2 years. pocket mask. Awareness and Education All building occupants. 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. Develop a Program Budget This should include the cost of the device.

3. An employee in Human Resources was selected to serve as the primary in-house AED program coordinator. called “fire marshals. Based on the AHA recommendations to provide defibrillation within 3 to 5 minutes of collapse. Feedback should be provided both to individuals and to the entire response team. the company decided to implement an AED program in their office in Pittsburgh. scissors. 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. Regular reminders about when and how to activate the response team should be provided to all building occupants. response plan. Soon after. 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. Placement of the AED was the first.Chapter 13 / Public Access Defibrillation 241 Fig. The next order of business was determining who would be trained to use the AED. and supplied with ancillary items such as a razor.” that had . Creating such a response system involved several components. the program coordinator and medical consultant should evaluate individual responses and use of the AED. towel. 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. After every event. CPR pocket mask. Pennsylvania. and alcohol wipes. The Hillman Company already had a group of employees. The AEDs were placed in high-traffic areas. it was determined that the Hillman Company would need an AED on each floor of the building they occupy. All employees were alerted regarding the location of the devices. Symbol for AEDs promoted by The National Center for Early Defibrillation. especially the timeliness of response.

SUMMARY Although sudden CA remains a leading cause of death in the Western world. that if a CA event does occur. The Hillman security system is used to activate the on-site response plan. and are becoming less costly. This group. A Short History of Modern Resuscitation 1904: 1933: 1946: 1947: George Crile performs first American case of closed-chest cardiac massage. not been put to the test in a real situation. These devices allow lay bystanders and nonmedical emergency responders to provide defibrillation—the only known effective therapy for VF. together with the data stored in the AED. require low maintenance. checklists for the maintenance of the device. 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. AEDs are safe and effective. however. along with some additional volunteers. the marshal places the call directly to 911. the medical director will be contacted within 24 hours to review the response.242 Cardiopulmonary Resuscitation volunteered to lead an evacuation of the building in the case of fire. publish study on initiation and erasure of VF with electric shocks James Elam performed mouth-to-nose ventilation on polio patients Claude Beck successfully defibrillates 14-year-old boy using open-chest massage and AC defibrillator . procedures for the reporting any event involving the AED to the medical director. fortunately. The program was registered with the State of Pennsylvania’s Emergency Medical Services Institute. was trained in CPR and AED through the AHA Heartsaver AED course. the names of the emergency response marshals. Public access defibrillation is a critical component of the optimal intervention strategy for combating sudden CA. A growing number of communities and specific venues have reported successful early defibrillation programs. the advent of AEDs is allowing a new assault on this stealth. The manual includes information such as the placement of the AEDs. Security buttons existed throughout the company under desks and near phones. retrieves an elevator and guides the emergency medical technicians to the patient. the program has. The guard. Although tested in a successful mock drill. easy to use and difficult to misuse. in turn. and answers to frequently asked questions about AEDs. the on-site emergency response plan should ensure rapid and effective treatment. an explanation of how to perform CPR and use the AED that they had purchased for the company. silent killer. 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. the procedures for calling for help. calls 911. William Kouwenhoven et al. It was established that if the AED is ever used. Pressing one of these buttons alerts the guard at the front lobby security desk when and where an emergency occurs. If alone. After hours when no guard is on duty. They have been recertified every 2 years and receive shorter refresher training every 6 months. Hillman Company employees can rest assured. for the purpose of quality improvement. and coordinated with the local ambulance service to help ensure seamless transfer of care.

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