Effective Early Defibrillation Programs

Manage the logistics to maximize your response to sudden cardiac arrest.

• By Bill Clendenen, A.B., MBA, Bill Rowe
• Dec 01, 2004

A co-worker in his early fifties collapses from sudden cardiac arrest (SCA) after taking a walk during his break. He's unresponsive, turning blue, and lying motionless on the floor just inside the main entrance. You activate your emergency response plan, call 911, and wait. Within three minutes, CPR is started by trained co-workers. Six minutes later, EMS arrives and begins advanced care.

At most, your co-worker has only a 5 percent chance of surviving this event.¹

You have met OSHA guidelines² for emergency response, but there's more you can do to improve survivability for workers who have experienced SCA. Automated external defibrillators in coordination with trained bystanders can improve survivability substantially, in some cases as high as 80 percent.³ The steps to implement an effective early workplace defibrillation program are not difficult, and the results can be incredible.

Approximately 340,000 people die each year from SCA⁴, with the most common cause being an abnormal heart rhythm known as ventricular fibrillation. VF is an electrical malfunction resulting in a chaotic quivering of the heart that produces no outward blood flow. Victims become unresponsive, collapse, and stop breathing. Within minutes, the brain begins to become injured from the lack of oxygen; without prompt treatment, death of the victim will quickly follow. Typically, survival rates from SCA have been very low, with most rates hovering around 5 percent in most areas.

The only definitive treatment for VF is defibrillation. An electrical shock to the heart, defibrillation terminates life-threatening rhythms like VF and allows normal heart rhythms to recur. In recent years, bystanders' use of an AED has been gaining increased acceptance by businesses and the general public within public access and corporate defibrillation programs. Many organizations are now seriously considering the implementation of AEDs in the workplace.

Where to Start? The Site Survey
To be most effective, a defibrillator and someone trained in its use need to get to a victim of sudden cardiac arrest within three to five minutes of the collapse (OSHA, AHA). Speed is essential. For every minute defibrillation is delayed, the chance of successful resuscitation decreases by about 7-10 percent.⁵

In order to achieve a defibrillation response time goal of three to five minutes, it is first necessary to gather pertinent information about your facility and your current emergency response capabilities. This allows for a systematic determination of how many defibrillators are appropriate, where they should be placed, and whether additional resources are needed. To gather this information, you need to conduct a site survey of your facility.

The site survey should evaluate:

* Property size and layout, single or multiple sites.
* Barriers to responders, such as restricted areas, long distances to travel, multiple floors, or multiple buildings.
* Hours of operation and peak traffic areas.
* High-risk areas, such as areas of dense population, high voltage, fitness facilities, heavy equipment, or machinery.
* On-site emergency responders, response times, and levels of training.
* How on-site emergency responders and EMS are notified.
* Local EMS agency response times and levels of training.

Regulatory Considerations
Next, you will need to review any state and local regulatory requirements for early defibrillation programs. These can be found at a variety of Web sites. Good resources include The National Center for Early Defibrillation's site, www.early-defib.org, which has links to all of the state legislation regarding AEDs⁶, and The National Conference of State Legislatures' site, www.ncsl.org/programs/health/aed.htm (click on "Public User"), which provides a summary of the state laws regarding AED use and links to the individual legislation. These sites will list state requirements for having an early defibrillation program.

All 50 states have enacted "Good Samaritan" protection to limit AED liability. Varying by state, these laws are designed to help protect responders who use the devices, companies or institutions purchasing them, physicians providing oversight, and trainers who teach defibrillator use. The federal government has also enacted legislation that affords limited liability for federal employees trained to use AEDs.

In most cases, liability protection is dependent on certain "conditions of use" being met during implementation of a workplace AED program. Common conditions include training in CPR and use of the AED; medical oversight; local EMS notification; program quality assurance; recordkeeping; and reporting.

Once you've determined the number and placement of the AEDs and reviewed the laws applicable for your AED program, you're ready to begin putting all of the pieces together.

Key Elements of an Early Defibrillation Program
* The defibrillator: There are more than 10 different types of automated external defibrillator currently available on the market from a multitude of manufacturers. All of them provide essentially the same thing: voice instructions describing operation of the device, analysis and identification of VF, and the ability for responders to deliver shocks to patients. However, each device has unique features and benefits, and it is important to select a device that best meets your company's needs.

* Defibrillator accessories: Consumable supplies such as defibrillation pads and batteries are necessary for the operation of an AED. Other accessories, such as scissors, towels, or resuscitation masks, can be very useful when operating the device. In addition to initial cost of the device and accessories, make sure to consider the anticipated cost of replacement supplies and ongoing maintenance.

* Early defibrillation program manager: Choose an early defibrillation program manager who can administer the logistics of the program and communicate well with program stakeholders, such as senior management, safety committee members, emergency responders, and employees. For multi-site organizations, program managers can use site coordinators to help in program maintenance. Program managers: communicate with local EMS on early defibrillation program issues; participate in case reviews, responder training and retraining, data collection and other quality assurance activities; maintain the emergency response plan and AED program policies and procedures; maintain a roster of trained early defibrillation responders; and ensure compliance with state and local regulations regarding defibrillator use.

* Medical direction/coordination: The U.S. Food and Drug Administration requires a physician's prescription for the purchase of an AED. Depending on state legislation, you may be required to have a physician provide oversight of your AED program, including review of your AED protocols of use, general policies and procedures for the program, and training programs you use when training responders.

Once an early defibrillation program has been established, it also may be required for a physician to review any incident of actual AED use that occurs at a facility. Regardless of patient outcome, the purpose of the review is to identify areas of weakness in the response to the emergency and make suggestions for improvement.
* Training: You need to integrate AED training into existing workplace cardiopulmonary resuscitation and first aid training. AED training programs are available from national training organizations. Most AED training is combined with CPR training in a three- to four-hour course. It can be added as a supplement for current CPR or CPR/first aid trained responders.

Advances in defibrillator technology have made automated external defibrillators much easier to operate, even with limited training. Nevertheless, training responders in the broader concept of responding to and managing a sudden cardiac arrest event can go a long way in ensuring a successful resuscitation. Most trained personnel go for long periods of time without being called on to use a defibrillator. Refresher training is essential to keep responders sharp and their confidence high. Check your state and local regulatory requirements for retraining. Most training certifications are valid for up to two years. However, some states require more frequent retraining.

Training Considerations
Training can be conducted in-house or contracted through outside resources. Consider the following points when developing an AED training program:

* Who will be trained?
* What are the state or local training requirements for AED programs?
* Who will conduct the training program?
* How will training be accomplished--all at once or over time?
* How frequently will users be trained or retrained?

Most AED training organizations follow national guidelines for training in the use of defibrillators. Minimum topics include:

* Initial assessment
* Airway management including choking maneuvers
* Rescue breathing
* CPR
* Use of a defibrillator
* Defibrillator maintenance and troubleshooting
* Organization-specific policies and procedures
* Hands-on practice of cardiac arrest scenarios incorporating CPR and the defibrillator
* Written and practical evaluation as required.

EMS Integration: Linking with Professional Responders
Many states require companies to coordinate their AED program with local Emergency Medical Services. It's important to inform EMS that your company has AEDs in its facilities and where they are placed. In an emergency, EMS dispatch may be able to direct the caller to the location of the nearest AED. You should also discuss with EMS how they will respond to the emergency and what steps they are likely to take once they come on the scene.

Also, after a sudden cardiac event occurs, it is critical to review the response and look for areas of improvement and coordination. This meeting should include the AED program manager, medical director, local EMS, and the emergency responders who were involved in the emergency.

Ongoing Maintenance
A very important component of an AED program is an effective maintenance process. Once implemented, it may be several months or even years before a defibrillator is actually used. During this time, pads may expire and dry out, batteries may go dead, and responders' training may expire. Ensuring the "readiness" of defibrillators needs to be an ongoing priority. To help, defibrillators perform regular maintenance self-checks to ensure they are ready for use. In addition, periodic physical checks of each AED should be performed, including:

* Verification of open access and clear signage
* General cleanliness
* A check of the device's status indicator
* A check of supplies, such as barrier devices, scissors, extra battery, spare pads, etc.
* The presence of all required supplies, and
* The expiration dating on the pads and batteries.

A defibrillator equipment and maintenance worksheet is useful to record and track changes. New, online AED maintenance tracking programs can provide easier documentation and useful services, such as detailed device and training reports and e-mail reminders on upcoming expirations of accessories and training. Be aware of state or local regulations regarding AED maintenance.

Policies and Procedures
An emergency response plan that identifies how and when lay rescuers will respond to emergencies is essential to a successful early defibrillation program plan. The plan should be defined in formal policies and procedures. It should include:

* Identification and structure of the basic components of the program.
* Early defibrillation response protocols, including how early defibrillation responders and local EMS are notified in the event of an emergency.
* The procedures that are followed after responding to an emergency incident.
* In addition to response procedures covering normal business hours, special procedures for alternate shifts, times of reduced or increased occupancy, and coverage during organizational functions.

A written policies and procedures document detailing all aspects of the early defibrillation program is essential. This document should include:

* Emergency response plan
* Training requirements
* Early defibrillation response protocol
* Post-incident procedures
* Maintenance procedures and schedule.

It also should identify the program manager, medical director, any site coordinators, and emergency responders.

Managing Liability and Risk
The concept of significant risk for companies that purchase AEDs and implement early defibrillation programs has proven historically not to be true. Liability has been reduced by Good Samaritan immunity legislation, insurance, and device indemnification through AED manufacturers. To keep risk low, it is important for companies that want to adopt programs to be diligent about implementation and ensuring the ongoing readiness of their programs.

An interesting development in AED liability is seen in cases where lawsuits are brought upon organizations for not having AED programs in place when other similar organizations have. By having an AED program, a business or company may actually have a lower legal risk.⁷

Documentation is critically important in the defense of liability. Elements of an early defibrillation program that are essential to track are:

* Defibrillator status: Installed and in service, pads and batteries have not expired.
* Responder training: Training for emergency response team members is up-to-date and certifications are current.
* Additional training exercises documented: Sudden cardiac arrest drills, meetings
* Regulatory requirements still in compliance.

The online maintenance programs discussed earlier are extremely useful in helping companies track AED program compliance and maintain readiness.

Results
An effective early defibrillation program produces significant results. Studies from a variety of industries demonstrate survival from sudden cardiac arrest can improve from approximately 5 percent when an AED is not available to more than 50 percent when it is.⁸ In Las Vegas casinos, response by trained rescuers showed survival increased to over 70 percent.⁹

OSHA states that "Employers should consider use of AEDs at their worksites to reduce the time to defibrillation with the goal of improving survival."¹⁰ With 13 percent of all workplace death (815 out of 6,339 deaths in 1999 and 2000) attributed to sudden cardiac arrest, effective AED programs that provide an AED response time of less than five minutes could save 160 lives out of the 400 deaths from SCA in the workplace.

AEDs are here to stay, and their use in the workplace is rising rapidly. A well-designed and -maintained early defibrillation program can provide your employees and visitors the greatest possible chance of surviving a workplace-related sudden cardiac arrest.

References
1. Cummins RO, et al. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC); Page I-71; American Heart Association.
2. Occupational Health and Safety Administration (OSHA); Standards 29 CFR, Subpart K, Medical services and first aid.--1910.151, 1998.
3. Valenzuala TD, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine; 343:1206-1209; 2000.
4. American Heart Association. Heart Disease and Stroke Statistics--2004 Update. Dallas, TX; American Heart Association; 2003.
5. Cummins RO, et al. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC, Circulation (Suppl) 2001);102:8, August; Larsen MP, Eisenburg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med 1993; 22:1652-1658.
6. Lazar R.; Understanding Legal Issues; National Center for Early Defibrillation; http://www.earlydefib.org; 2000.
7. Lazar R.; Liability no Barrier--AED Programs Can Reduce Legal Risk. National Center for Early Defibrillation; http://www.earlydefib.org; 2003.
8. Caffrey S, Willoughby PJ, Pepe P, Becker LB. Public use of automated external defibrillators. New England Journal of Medicine; 347:1242-1247; 2002.
9. Valenzuala TD, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine; 343:1206-1209; 2000.
10. Occupational Health and Safety Administration (OSHA); Cardiac Arrest and Automated External Defibrillators (AEDs). Technical Information Bulletin 01-12-17; 2004.

This article originally appeared in the December 2004 issue of Occupational Health & Safety.