Imagining a World with All the AEDs We Need

In a world with more AEDs, setting up and running a thoughtfully designed, well-prepared, and high-performance AED program is a very attainable goal.

• By Richard A. Lazar
• Jun 01, 2019

This is the third in a series of articles on the state of affairs in public access automated external defibrillator (AED) programs and the challenges and opportunities we face in deploying them for optimum community preparedness.

In the first article¹ in this series, "Squad Goals: Moving the Needle on Sudden Cardiac Arrest Requires a New Model," we highlighted reasons the survival rate from sudden cardiac arrest (SCA)—the third-leading cause of death in the United States—remains at a stubbornly low 6 percent, despite more than 30 years of effort, and we offered a new model called the "AED Response Squad" for moving the survival needle. In the second article,² "A New Model for Increasing Cardiac Arrest Survival Requires We Fix the National AED Shortage, Too," we exposed the shocking shortage of automated external defibrillators (AEDs) in the United States and offered a Model AED Law that, if enacted in every state, would ensure an abundance of these life-saving devices and move us closer to our ultimate goal.

In this third and final installment, we imagine that we've been successful in broadly applying the AED Response Squad model and passing the Model AED Law, dramatically increasing available AEDs and improving SCA response. As we imagine this new world with lots of AEDs, we explore what it will take to fully leverage these critical public health resources to maximize SCA survival. In order to be successful, this new world must also include AED program preparation and performance.

Sudden Cardiac Arrest Response in Context
At a macro level, the sheer magnitude of sudden cardiac arrest as a public health threat is easy to describe. Nearly 400,000 people experience SCA outside of hospitals in the United States every year. Approximately 120,000 of these—roughly 30 percent—are stricken in public settings outside of the home. We know conclusively that quickly delivering cardiopulmonary resuscitation (CPR) and defibrillation with an AED can save the lives of many SCA victims. But as of 2019, only 6 in 100 survived in public settings because there were too few volunteer rescuers willing to help and too few available AEDs.³ That's the macro story.

In a world where states pass the Model AED Law,⁴ resulting in the placement of millions more AEDs, it will certainly be true that a life-saving device will more often be nearby when SCA strikes. But, for AED programs, the timely application of CPR and defibrillation therapies to the people who need them when they need them is the most critical requirement. It is at this micro level where things get challenging.

To understand this challenge is to understand that AEDs alone do not save lives. Rather, people quickly performing CPR and using AEDs save lives. For this to happen, organizations with AEDs must be properly prepared and must perform responsibly (not perfectly) in sudden cardiac arrest emergencies.

AED Program Preparation
The term "AED program" is used extensively in and around this industry. But if you ask 10 people what the term means, you're likely to get 10 different answers. So let's start by defining the concept.

An AED program is comprised of a set of policies—sometimes written; often not—that prepare an organization to help someone experiencing sudden cardiac arrest. These policies organize the people, systems, equipment, and activities of an AED program. Industry standards,⁵ applied in the context of an organization's particular physical and human characteristics, guide what to include in AED program policies (see Get to Know the AED Program Rules⁶ to learn why AED laws are not industry standards).

The first step in AED program preparation involves the development of an AED program design. AED program design decisions dictate the content of an AED program's policies, influence how well-prepared an organization is for SCA emergencies and impact how well it performs when one occurs.

Two important factors must be kept in mind when constructing an AED program's design and policies. First, it is impossible to predict the precise locations where any of the annual 120,000 public setting SCA episodes will occur. And because these episodes are so geographically disbursed (e.g., a health club, shopping mall, office, warehouse, manufacturing plant, school, place of worship, coffee shop, grocery store, etc.), SCA occurrence in any single location is incredibly rare, with an episode expected perhaps once every 10 to 40 years. This means that, in a world with tens of thousands more AED programs, each AED program site must remain prepared for SCA emergencies that may happen at any time over long periods of time.

With this background in mind, here are some AED program design elements and policy examples (not an exhaustive list) that can help prepare an organization for long-term success.

• Identify key characteristics of each AED program site: An organization's physical, operational, and personnel profile drives many AED program design and policy decisions. Characteristics include things such as the number of sites and buildings and their size (horizontally and vertically), physical factors that can impede movement (stairs, doors, elevators, etc.), the number of daily employees and visitors, and staff turnover rates, among others.
• Assign people to administrative and operational roles: It is important that one person be in charge overall of an organization's AED program. Certain administrative (e.g., fulfill regulatory requirements, document policies, etc.) and operational (e.g., training, equipment purchasing, etc.) tasks can be delegated, but there should be one person who "owns" preparation and performance responsibilities.
• Establish a reasonable AED response time objective: "AED response time" is the total time between SCA recognition and AED use. An organization's AED response time policy sets a goal for how quickly AED use is expected to happen and guides how many AEDs are needed to meet the goal. A response time goal of five minutes or less is recommended to avoid the three-minute response time trap,⁷ and a written policy documenting this objective is critical for risk management purposes. Few organizations create a written response time policy, which opens the door for plaintiffs' lawyers to argue in negligence lawsuits for a shorter, unfair standard.
• Define AED response areas and AED placement locations: Given the relationship between the time to defibrillation and the chances of SCA survival, an AED can cover a limited area. The size of the area is impacted by the organization's physical characteristics and response time objective. Specific areas covered by each AED, including its precise placement location, should be documented in AED program policies.
• Establish the AED response squad: This is a complicated issue, muddied by confusion over the role formal CPR/AED training should play and the existence of unhelpful AED law training requirements. Successful AED programs leverage both trained and untrained volunteer bystanders to aid in SCA emergencies. A policy that specifically authorizes any willing bystander to voluntarily perform CPR and access, retrieve, and use an AED creates the highest likelihood someone will step in to help.

Many other design and policy elements guide and support a successful AED program. Learn more about these in the national AED Program Design Guidelines™.⁸

AED Program Performance
AED program performance is gauged by what people do and how equipment functions at an AED program site when SCA strikes. Key performance elements include SCA recognition, 911 call for help, CPR, and AED retrieval and use.

• SCA recognition: The CPR/AED response time clock starts running only after SCA is first recognized. But, when measuring AED program performance for CPR and AED use, it is essential to acknowledge that it remains quite difficult for lay bystanders—including those who have received formal training—to timely and accurately recognize sudden cardiac arrest. One recent study found CPR wasn't started because of perceived breathing⁹ upwards of 46 percent of the time. In another, more than 20 percent of laypersons were unable to determine whether an SCA victim was breathing and required CPR.^10,11 A recent National Academy of Sciences Institute of Medicine study highlights how lay bystanders often mistake SCA for a seizure or fainting. While neither desirable nor ideal, a failure to timely recognize SCA does not necessarily mean poor AED program performance. This issue comes up in negligence lawsuits claiming delayed CPR or AED use and should be judged by what can reasonably be expected of volunteer lay rescuers.
• Summoning emergency medical services: Because of the importance of advanced cardiac life support in SCA treatment, one measure of AED program performance is how quickly 911 is called to summon professional emergency medical services assistance. The good news is that 911 is called quickly in most cases of sudden cardiac arrest, even when SCA may not have been properly recognized.
• CPR delivery and performance: The time it takes to start CPR after SCA is first recognized is another performance measure. Whenever started, it is important to note that CPR is a difficult skill to master for both volunteer bystanders and professional rescuers alike. CPR feedback devices—stand-alone or built into AED technology—are now emerging as a tool to help improve the quality of CPR, which is certainly a good thing. But this technology also has been used as a weapon in an administrative proceeding involving two EMTs fired allegedly because CPR feedback technology showed poor-quality CPR. This sets a dangerous precedent that may discourage volunteer bystanders from providing CPR at all.
• Equipment readiness: According to industry standards, AED laws in more than 30 states, and manufacturer guidelines, AED owners have an obligation to properly inspect and maintain their devices. AEDs absolutely must work when needed, a key measure of AED program performance. Yet more than 20 percent of AEDs deployed today in the United States may not be ready. Whether using a do-it-yourself AED inspection program or a remote AED monitoring system like AED Sentinel®, AED program managers must ensure AED readiness, even over long periods of time. This is perhaps the most non-negotiable and binary element of AED program design and operations.

Many other performance elements make up a successful AED program. Again, learn more about these in the national AED Program Design Guidelines™.¹²

In a world with more AEDs, setting up and running a thoughtfully designed, well-prepared, and high-performance AED program is a very attainable goal. AED programs offer significant benefits to an organization's health and safety program, its employees and visitors, and, ultimately, to the survivors of sudden cardiac arrest. It's a worthy endeavor indeed, and one that shouldn't wait for a new, idyllic world in order for us to start taking the steps toward achieving it.

References
1. https://ohsonline.com/articles/2018/10/01/squad-goals.aspx
2. https://ohsonline.com/articles/2019/01/01/a-new-model-for-increasing-survival.aspx
3. https://readisys.com/the-aed-shortage/
4. https://readisys.com/get-to-know-the-aed-program-rules/
5. https://readisys.com/aed-program-design-guidelines/
6. https://readisys.com/get-to-know-the-aed-program-rules/
7. https://readisys.com/avoid-the-3-minute-aed-response-time-trap/
8. https://readisys.com/aed-program-design-guidelines/
9. Bystander-witnessed cardiac arrest is associated with reported agonal breathing and leads to less frequent bystander CPR. Brinkrolf et al. Resuscitation 127 (2018) 114-118.
10. Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher-assisted cardiopulmonary resuscitation instruction. Fukushima et al. Emerg Med J 2015;32:314-317.
11. See also, 'She's sort of breathing': What linguistic factors determine call-taker recognition of agonal breathing in emergency calls for cardiac arrest? Riou et al. Resuscitation 122 (2018) 92-98. ("[L]ay rescuers often mistake agonal breathing for effective breathing and thus [cardiac arrest] patients can be incorrectly assessed as breathing.")
12. https://readisys.com/aed-program-design-guidelines/

This article originally appeared in the June 2019 issue of Occupational Health & Safety.