Automated External Defibrillation in the Occupational Setting

On November 13, 2000, President Clinton signed into law H.R. 2498, the Cardiac Arrest Survival Act, designed to expand the availability of automated external defibrillators (AEDs) in public settings and that required the Secretary of the Department of Health and Human Services to establish guidelines for the placement of AEDs in buildings owned or leased by the federal government. In May 2002, President Bush signed into law the Community Access to Emergency Devices Act within H.R. 3448 (sections 159, 312, and 313) of the Public Health Security and Bioterrorism Response Act, and on June 12, 2002, he finalized this as Public Law 107-188. The provisions authorized the availability of grants to states and localities for the purchase and placement of AEDs in public places where cardiac arrests are likely to occur and encouraged private companies to purchase AEDs and to train employees in cardiopulmonary resuscitation (CPR) and emergency defibrillation. To support AED federal legislation, to increase awareness and value, and to offer recommendations about AEDs in the occupational setting, the American College of Occupational and Environmental Medicine (ACOEM) has included the AEDs in the Workplace Web site, containing survey data, case studies, reference database, and other academic and practice resources, in their Health and Productivity Management Center.1 ACOEM also issued in 2001, and reaffirmed in 2006, a position statement on AEDs in the workplace.2 This document updates that statement by addressing the following topics: (1) history and overview of AEDs; (2) epidemiology, morbidity, mortality, and incident locations; (3) sudden cardiac arrest (SCA) and the “chain of survival” paradigm; (4) AED technologies; (5) public-access defibrillation; and (6) guidance for the use of AEDs in occupational settings. HISTORY AND OVERVIEW OF AEDS Making its debut in 1979, the term “AED” commonly refers to any device that analyzes cardiac rhythm and enables the delivery of an electric shock when necessary.3 Utilizing solid-state circuitry and microcomputer technologies, AEDs identify ventricular fibrillation (VF) and ventricular tachycardia (VT) then voice prompts a user to prepare for delivery of a shock. Two modes of AED are available. An “automated” AED analyzes then prompts a user to press a button to deliver a shock. Some AEDs are multifunctional and can be set to operate in “automatic” mode, which analyses and delivers a shock without a user prompt. Annual sales and the total number of AEDs in the United States are difficult to confirm. One study published in 2006 estimated that more than 200,000 are sold annually for public use in the United States.4 A 2011 industry report estimated that total US sales in 1996 were approximately 18,645 devices, and by 2006 total sales had reached more than 775,000, an increase of 30% per year over the decade.5 Annual revenue forecasts for the defibrillator market by 2015 are estimated to be $1.7 billion in the United States,4 and when implantable cardioverter defibrillators are included, in excess of $11 billion globally.6 Submitting key words, “automated external defibrillator,” to the National Library of Medicine's pubmed.gov search site produces more than 11,000 scholarly papers written about AEDs including clinical and field reports. Although some devices have had safety alerts and recalls commonly attributed to manufacturer quality control,4,7 most research has demonstrated that overall, devices are safe, effective, accurate, and increasingly cost-effective.8–12 As AEDs are easy to transport due to reduced size and weight (less than 7 pounds),13 and because federal and state legislation enables and provides liability protection to acquirers and users,14 AEDs are a standard of care device for health and allied health providers and are commonly available within medical institutions and for emergency medical services and fire departments, and police officers.15,16 More than 30 years of evidence has also shown that little or no training or education is required for proper use,17–20 because devices have easy-to-follow audio and visual prompt instructions,21–23 or operate automatically without user decision making after pads are placed on the chest of the patient. For these reasons, AEDs are commonly available for voluntary emergency first aid responders and untrained bystanders who may be present at the scene of a cardiac arrest. This open access is promoted in part because the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations published by the International Liaison Committee on Resuscitation (ILCOR), which represents principal resuscitation organizations worldwide including the American Heart Association (AHA), European Resuscitation Council, and the Heart and Stroke Foundation of Canada has recommended that “AED use should not be restricted to trained personnel. Allowing the use of AEDs by persons without prior formal training can be beneficial and may be lifesaving. Because (however) even brief training improves performance (eg, speed of use, correct pad placement), it is recommended that training in the use of AEDs be provided.” 24 As rapid use saves lives, AEDs are available for lay citizens across a broad spectrum of private and public locations including airports, casinos, community centers, educational institutions, and sports and shopping centers, and in tens of thousands of occupational settings where they are provided for use by health care and nonmedical first aid responders. Indeed, data collected from May 1, 2006, to April 30, 2007, from the Resuscitation Outcomes Consortium, an observational study involving 13,769 out-of-hospital cardiac arrests from 10 North American sites (8 US and 2 Canadian), showed that overall survival to hospital discharge was 7%, survival with bystander CPR but no AED was 9%, and when an AED was used and shock delivered survival was 38%.25 EPIDEMIOLOGY, MORBIDITY, MORTALITY, AND INCIDENT LOCATIONS Cardiovascular diseases (CVD), including coronary heart disease and SCA, remain significant concerns to general public health and the occupational setting in particular. According to the 2011 statistical update provided by the AHA an estimated 82,600,000 American adults have one or more types of CVD.26 Of these, 40,400,000 are estimated to be younger than 60 years. Total CVD includes 76,400,000 people with high blood pressure, 16,300,000 with coronary heart disease, 7,900,000 who experienced myocardial infarction, 9,000,000 with angina pectoris, 5,700,000 with heart failure, and 7,000,000 who experienced a stroke. The AHA noted that CVD accounted for 33.6% (813,804) of all 2,243,712 deaths in 2007 (the most recent data available), an average of one death every 39 seconds.25 Data have also indicated that approximately one of every six or 406,351 deaths in the United States resulted from coronary heart disease. The AHA estimate for 2011 is that 785,000 Americans will have a new coronary attack, approximately 470,000 will have a recurrent attack, and an additional 195,000 silent first myocardial infarctions will be identified. A significant number of cardiac arrests occur in out-of-hospital locations. Out-of-hospital cardiac arrests data collected by emergency medical service programs in Seattle and King County, Washington, from January 1, 1990, through December 31, 1994,27 revealed that public sites represented 16% of incidents. The Resuscitation Outcomes Consortium examined the period 2005–2007 for seven US sites (Alabama, Dallas, Iowa, Milwaukee, Pittsburgh, Portland [Oregon], and Seattle and King County) and three Canadian sites (Ottawa, Toronto, and Vancouver) and reported 12,930 out-of-hospital cardiac arrests, of which 15.8% occurred in public locations.28 In a 2007 report of the Save Hearts in Arizona Registry and Education program, which reviewed emergency medical services (EMS) first-care reports submitted voluntarily by 30 municipal fire departments responsible for approximately 67% of Arizona's population, the total number of out-of-hospital adult arrests of presumed cardiac etiology reported statewide was 1097.29 Of these, 15% occurred in public locations. There are several electrical abnormalities that result in SCA, but the majority of deaths begin with an initial rhythm of VF.30–32 If VF is not treated quickly, nearly all patients degenerate to asystole,33 which is fatal.34 In patients known to have ischemic heart disease, the out-of-hospital cardiac arrests incidence of VF and VT is 80% to 90%.35 Over the past three decades, the recorded incidence of VF or pulseless VT as the initial rhythm encountered by EMS in out-of-hospital cardiac arrests has decreased significantly,36,37 from approximately 70% to 23%,25,38 with an overall incidence of 26%.27 Ventricular fibrillation or VT is higher for bystander-witnessed events in public and occupational settings, because bystanders arrive sooner than EMS; thus, survival to hospital discharge is nearly three times higher when an AED is applied by a lay responder after a cardiac arrest in a public location than in a private home where the initial assessment and responses are primarily made by EMS (34% vs 12% for arrests at home).39 The consensus of science to correct VF and pulseless VT is immediate chest compression followed by a single electric shock with a controlled dose and duration of energy followed by resumption of chest compressions. If circulation does not return, this is followed by a sequence of compression and electric shock with the same or with increasing energy levels.40 Cardiopulmonary resuscitation without electric therapy may sustain a patient in VF for a short time but only rarely restores an organized rhythm. Indeed, performing CPR in the period of 1.5 to 3 minutes before defibrillation does not necessarily improve survival for patients with out-of-hospital VF or pulseless VT.41,42 And delaying CPR even for AED rhythm assessment is associated with decreased probability of conversion of VF to another rhythm.42,43 As return of an adequate perfusing rhythm requires immediate application of the combination of CPR, defibrillation, and pharmacotherapy as soon as possible after arrest, establishing controls to support these enhances the probability of survival. SUDDEN CARDIAC ARREST AND THE CHAIN-OF-SURVIVAL PARADIGM Factors contributing to out-of-hospital survival following SCA have been described primarily in terms of a time-related, linear chain-of-survival paradigm.44,45 The sequential interventions (links) leading to survival are (1) early recognition and call for EMS; (2) early initiation of basic life support CPR; (3) early defibrillation (AED); and (4) early advanced (cardiac) life support (ALS) primarily involving drug intervention protocols. Following the release of the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, a fifth link, integrated post–cardiac arrest care, was added.46 Sudden cardiac arrest survival has been described as dependent on the sequential availability of the links although more advanced applications may jump ahead of lesser ones. For example, if workplace allied health personnel or the arriving community EMS responders are not qualified or prepared to deliver ALS, this link may not be available until the patient arrives at a medical center. If CPR-trained first aid responders initiate chest compressions in conjunction with an AED, and this is quickly followed by intervention by ALS-level responses, then timing between these links will likely be shorter. In a systematic review of literature through 2008, the factors most correlated with survival to hospital discharge following out-of-hospital cardiac arrest were witnessed by a bystander, witnessed by EMS, applying bystander CPR, being found in VF or VT, and achieving return of spontaneous circulation.47 Without intervention, survival following SCA decreases rapidly to zero. Several studies have reported that for each minute of untreated cardiac arrest, the probability of successful rhythm conversion decreases by up to 10%, producing an equivalent per-minute-death rate.48,49 Conversely, survival rates as high as 90% have been reported when the collapse-to-defibrillation (“drop-to-shock”) time is within 1 minute.50–52 To empirically define the contribution of each link in the chain of survival, data from the Seattle experience were examined between 1976 and 1991.49 A best-fit model demonstrated the following equation: Survival rate = 67% at collapse − 2.3% per minute to CPR − 1.1% per minute to defibrillation − 2.1% per minute to ACLS As noted by the authors, The regression constant, 67%, represents the probability of survival in the hypothetical situation in which all treatments are delivered immediately after collapse to patients with prehospital cardiac arrest.... With delays in CPR, defibrillatory shock, and definitive care, the magnitude of the decline in survival rate per minute is the sum of the three coefficients (−2.2%, −1.1%, −2.1%), or −5.5%.49 Although the chain-of-survival paradigm is an established metaphor, some argue that it is too simple because the forces that affect survival are complex.53 For example, when the four survival categories are examined in more detail, at least 50 “known or speculative” and additional “yet to be identified” factors not included in the chain can be acknowledged as influencing SCA survival.54 In addition, only approximately 7.9% of victims survive out-of-hospital cardiac arrest in the United States (a number that has not changed significantly in almost 30 years47) and there is a fivefold difference in survival rate among US communities.38 Thus, some commentators have for a of the to cardiac arrest in terms of and the use of a chain AED AED of and external defibrillators to several of the and some integrated as or are and with In an pulseless an AED will for and VT, or AED or in a single the rate at which the to is they are to as the rate is they are defibrillators deliver a sequence of in which the is of to the Although and are almost all AEDs provided are all of and AHA recommended that for a for defibrillation of pulseless cardiac arrest, it is to with an energy of to Although they that there is evidence to the initial energy for any other initial and this should be at Although there is total shock for in the of a a defibrillator is and use of a high initial energy is as of VF after the shock. defibrillation is a single shock should be provided with resumption of chest immediately after the shock. compressions should not be for rhythm or a immediately after a shock. 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