Part 12: Education, implementation, and teams

Clinical question. In adult and pediatric patients with out-of-hospital cardiac arrest (including residential settings) (P), does implementation of a public access AED program (I) as opposed to traditional EMS response (C), improve successful outcomes (O) (eg. ROSC, survival)?Is this question addressing an intervention/therapy, prognosis or diagnosis? intervention State if this is a proposed new topic or revision of existing worksheet: revisionConflict of interest specific to this questionDo any of the authors listed above have conflict of interest disclosures relevant to this worksheet? no Search strategy (including electronic databases searched).
ECC endnote library searched for "public access" in any field -57 references identified: 41 relevant.
Cochrane Database search for "public access defibrillation" -1 record found: preliminary report no abstract or report available
All reviewed articles had their reference sections hand reviewed and any relevant articles were obtained. The author also searched her personal reference library for relevant articles.
Search re-run 10/2/09 -0ne additional paper identified

## - state inclusion and exclusion criteria
No exclusion criteria were applied to the search strategy. For the article review only studies that discussed research were considered for the evidence table. Further, that research had to directly answer the worksheets clinical question and relate to responders who are not part of the formal EMS system including police and fire fighters. That is if responders were dispatched to the scene by emergency number (e.g., 911) dispatchers the study was excluded.
- Number of articles/sources meeting criteria for further review:
A total of 93 articles were reviewed.

## Reviewer's final comments and assessment of benefit / risk:
The AHA has previously defined 4 levels of public access defibrillation: level 1 traditional first responder (police/fire), level 2 nontraditional first-responder (security guard, flight attendant), level 3 citizen CPR (trained lay-providers), and level 4 minimally trained witness. . This worksheet focused on response outside of the traditional EMS system, levels 2, 3, and 4. The key study is the PAD trial (LOE 1), which demonstrated that twice as many cardiac arrest patients survived when PAD was available (93% CI 1.07-3.77) (Hallstrom, and that PAD programs were generally safe for both the patient and the rescuer. . PAD is also supported by four LOE2 studies, one LOE3, and 7 LOE4 studies. There is a single case study that illustrates an inappropriate shock being advised by an AED device, which is considered a negative study.( Nanthakumar 2006 pge672) However, this single negative case is far outweighed by the numerous positive studies with much larger sample sizes.
While there are no documented cases of harm being caused by a lay-provider using an AED, the cost and most logical deployment strategies are not clear and may vary by site and circumstances. For a PAD program to be effective it must be integrated into the formal EMS system. However, evidence shows that this is not consistently being done .
Initiating PAD programs is not without challenges. A study found that attrition of volunteer responders was 36% and that some locations do not have a ready pool of volunteer responders. pg688) Further, a large percent of lay-volunteers associated with a formal PAD program may not participate in retraining efforts, but the retention of CPR skills among lay volunteers may be high. pg52) But during an actual cardiac arrest event the number of CPR actions that are actually preformed by lay responders may be low. The cost effectiveness of placing an AED in a given location must also be considered. Research has shown that they are cost-effective when placed on commercial airplanes or other high incidence areas ; ; (Gold and Eisenberg 2007 pg1); ; but they may not be cost effective in low incidence areas. [bib_ref] Cost-effectiveness of automated external defibrillators in public places: con, Pell [/bib_ref] pg5) Several studies have looked at the location of cardiac arrests to try to predict high incidence locations. ; (Engdahl and Herlitz 2005 pg171); ; pg827) Prior to initiating a PAD program it is recommended that the likely incidence of cardiac arrest in that location be determined.
Use of AED's in the home by survivors of anterior-wall myocardial infarction showed that the presence of a home AED demonstrated no significant improvement in survival. However, the event rate in this population was low. The study did find that use of the AED in the home by lay-providers was feasible; it terminated ventricular fibrillation and did not result in inappropriate shocks. Therefore, home use of an AED is not harmful and potentially helpful, but because of the low likelihood of its use distribution to those who survive an anterior-wall myocardial infarction is unlikely to be cost effective or improve overall survival rates.

## Citation list
Articles used as Evidence . "Home use of automated external defibrillators for sudden cardiac arrest." N Engl J Med 358 (17): 1793-804.
Reviewer's Comment: Use of AED's in the home by survivors of anterior-wall myocardial infarction showed that the presence of a home AED had demonstrated no significant improvement in survival. However, the event rate in this population was low.
The study did find that use of the AED in the home by lay-providers was feasible; it terminated ventricular fibrillation and did not result in inappropriate shocks. Therefore, home use of an AED is not harmful and potentially helpful, but because of the low likelihood of its use distribution to those who survive an anterior-wall myocardial infarction is unlikely to be cost effective or improve overall survival rates.
Caffrey, S. L., P. J. . "Public use of automated external defibrillators." N Engl J Med 347 (16): 1242-7.
Reviewer's Comment: This case series looked at the deployment of AED across all three Chicago airports (LOE 4). They had good follow-up and survival to one year (quality -good). 11 of 18 ventricular fibrillation patients survived to hospital discharge with good neurologic function. They estimate the cost of the program is $3,000 per patient or $7,000 per life saved.
Capucci, A., D. . "Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation." Circulation 106(9): 1065-70.

## Reviewer's comment:
This non-randomized study recruited "lay-providers" who were taught to use an AED but were not taught CPR (LOE2 good quality). Thirty-nine AED's were then placed at 12 fixed locations (main public squares), 15 police and fire vehicles, and 12 public assistance vehicles. The authors then compared cardiac arrests treated by these providers over a 22 month period to those treated by EMS. This deployment method resulted in 40% of the 354 cardiac arrests being treated by the AEDs and found improved survival to hospital discharge and a higher rate of neurologically intact survival.
Colquhoun, M. C., D. . "A national scheme for public access defibrillation in England and Wales: early results." Resuscitation 78(3): 275-80.

## Reviewer's comment:
This non-randomized study compared static to mobile AED placement making it an LOE 2. There were 1,530 arrests studied and data was collected using a standardized report form making it a good quality study. Survival to hospital discharge was the outcome and it was found to be higher in the group treated by the static devices.
Culley, L. L., T. D. . "Public access defibrillation in out-of-hospital cardiac arrest: a community-based study." Circulation 109(15): 1859-63.
Reviewer's Comment: This is referred to as a cohort study but there is no control group (LOE 4). They report survival to hospital discharge for the 50 cases of cardiac arrest that were treated by one of the 475 PAD AED's that are deployed within King County in a 4 year period. They identified patients who were treated by one of their registered AED's as well as those treated by unregistered AED's (quality good). They examined survival rates (76% admitted, 50% discharged from hospital alive), but their main focus was on device usage. They found that these devices had 5 uses per 100 years of AED exposure.
Davies, C. S., M. C. . "A national programme for on-site defibrillation by lay people in selected high risk areas: initial results." Heart 91(10): 1299-302.

## Reviewer's comment:
This is a case series (no control) that describes a PAD program initiated in London LOE 4. They had difficulty obtaining hospital information, but were able to obtain survival to hospital discharge for all but 2 patients (quality -fair). The survival rate was 28.3% to hospital discharge. The program had 681 AEDs that were used 172 times or one AED use for every 120 defibrillator months. Note the same data is presented in Whitfield 2005 only the Davies article was included on the evidence grid so as not to double count a single study.
Eisenberg, M. S., J. . "Use of the automatic external defibrillator in homes of survivors of out-of-hospital ventricular fibrillation." Am J Cardiol 63 (7): 443-6.

## Reviewer's comment:
This project had a non-randomized pilot phase, then a randomized phase, and then a phase where all participants were offered an AED. All of these phases were reported together because there were only 14 out-of-hospital cardiac arrests making it a fair quality LOE 2 study. There was only 1 survivor in each group, but given the small sample size it is not possible to draw any conclusions on survival. Although, it does indicate that home AEDs may be rarely used. Reviewer's Comment: This study used historical controls from 1996 making it a fair LOE 3 study. It reported that neurologic status was obtained but reports survival to hospital discharge.
Hallstrom, A. P., J. P. . "Public-access defibrillation and survival after out-of-hospital cardiac arrest." N Engl J Med 351 (7): 637-46.

## Reviewer's comment:
This study was randomized at the community unit level (LOE 1). The number of actual arrests was far lower than what was expected. The program was detailed with good training for responders; therefore, the results only apply to programs with a training and response plan.
Jorgenson, D. B., . "AED use in businesses, public facilities and homes by minimally trained first responders." Resuscitation 59(2): 225-33.

## Reviewer's comment:
This survey asks AED owners about usage in the last year. The owners were identified though a single manufacturers customer database, the response rate was low (50-59%), and none of the patient outcomes were verified. Therefore, it was considered an LOE 4 study of poor quality.
Kuisma, M., . "Public access defibrillation in Helsinki--costs and potential benefits from a community-based pilot study." Resuscitation 56 (2): 149-52.

## Reviewer's comment:
This non-randomized study compared PAD sites to non-PAD sites. The sample size of cardiac arrests was small with 7 in the PAD group and 13 in the control group. All survivors were in the control group. There were no major adverse events reported. This study was considered LOE 2 because of the control group but of poor quality because of the small sample size which lead to the outcome being time to defibrillation. Nanthakumar, K. and S. C. . "Images in cardiovascular medicine. "Shock advised": inappropriate public access defibrillation." Circulation 113(13): e672.

## Reviewer's comment:
This is a case study of an inappropriate shock delivered by an AED. There is no outcome data provided for the patient and limited information regarding the incident.
O'Rourke, M. F., . "An airline cardiac arrest program." Circulation 96(9): 2849-53
Reviewer's Comment: This is a descriptive study that describes the PAD program initiated by Qantas Airlines for both its terminal and it large aircraft. The description is complete, although not a formal evaluation; therefore, it was rated as fair quality. They did obtain long term (2 year) patient outcomes.
Page, R. L., J. . "Use of automated external defibrillators by a U.S. airline." N Engl J Med 343(17): 1210-6.
Reviewer's Comment: This is a case series of patients treated on a commercial airline with an AED (LOE 4). The patients are followed to hospital discharge and neurologic outcome is measured. The records appear to be complete with the exception of some lost downloads, and all rhythms were analyzed by two specialists (quality good). . "Adverse events associated with lay emergency response programs: the public access defibrillation trial experience." Resuscitation 70(1): 59-65.
Reviewer's Comment: LOE 1, good study, outcome is adverse events or E. This studied shows that during the PAD trial there were limited adverse events. Six additional references were identified in this article. . "Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study." BMJ 325(7363): 515.

## Reviewer's comment:
This is a mathematical modeling study that used actual patient data when no AED was available and then predicted how a PAD program could have improved survival, therefore it is LOE 5. The quality is fair because they were not able to determine type of location for all patients and the survival endpoint was not defined. An endpoint of E was used since the survival variable was not defined. While the authors conclude that the increase in survival may not be cost effective, they did show an improvement in survival. Therefore, it is being considered supporting evidence for PAD programs. Letters to the editor were reviewed as well, no new references identified. . "Cardiopulmonary resuscitation alone vs. cardiopulmonary resuscitation plus automated external defibrillator use by non-healthcare professionals: a meta-analysis on 1583 cases of out-of-hospital cardiac arrest." Resuscitation 76(2): 226-32.

## Reviewer's comment: this meta-analysis included studies by kellerman and van
Alem which looked at first responder AED use and Hallstrom which look at layprovider AED use. This worksheet is looking at AED use compared to EMS response. First responder AED use is part of EMS response and thus these papers are actually comparing two different issues and for the purposes of this worksheet should not have been combined. Therefore, this does not provide any additional evidence for PAD programs beyond the contribution of the Hallstrom article. (2000) Valenzuela, T. D., D. J. . "Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos." N Engl J Med 343(17): 1206-9.
Reviewer's Comment: This case series (LOE4) was designed to evaluate survival to hospital discharge, therefore it was rated as a good quality study. It illustrates that security guards in public settings can use AEDs with positive outcomes. Reviewer's Comment: This paper was not included in the evidence grid since it presents the same data as Davies, 2005 and does not ask a different question. Therefore including it would be to double count this study.
Articles reviewed but not used as Evidence . "Public training in cardiopulmonary resuscitation and public access defibrillation." Ann Emerg Med 35(6): 640-1.

## Reviewer's comment:
This is a policy statement from the American College of Emergency Physicians on PAD. There is no research presented and there were no references provided. Reviewer's Comment: This study did not directly answer the worksheet question but it did show that a 2 hour CPR and AED course was enough to allow lay-responders to retain the training for one year.
Atkins, D. L., L. L. . "Automated external defibrillation/public access defibrillation." Ann Emerg Med 37(4 Suppl): S60-7.
Abstract: None available Reviewer's Comment: Review article. Two additional references identified. . "Prevalence of automated external defibrillators at cardiac arrest high-risk sites." Prehosp Emerg Care 8(3): 280-3.

## Reviewer's comment:
This study determined the rate of AED placement within a community. While it is relevant to the worksheet question it does not directly answer the question.
Becker, L., . "Public locations of cardiac arrest. Implications for public access defibrillation." Circulation 97(21): 2106-9.
Reviewer's Comment: This paper is relevant to the worksheet question but does not directly answer the question. Organizers of PAD programs should consider the incidence of cardiac arrest in a given location prior to starting a PAD program.

## Reviewer's comment:
This paper looked at psychological effects of responding, which is relevant but not the focus of this worksheet. Two additional references were identified.
Drezner, J. A. and K. J. . "Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases." Heart Rhythm 3(7): 755-9.
Reviewer's Comments: This Case series discusses the presence of AED's but combines those that were used by EMS and those used by Athletic Trainers. . "Localization of out-of-hospital cardiac arrest in and implications for public access defibrillation." Resuscitation 64(2): 171-5.

## Reviewer's comment:
This study is relevant to the worksheet question but does not answer the worksheet question. When considering PAD programs it is important to understand the potential impact this will have on the population. That is are these expensive devices likely to be used. Reviewer's Comment: This epidemiologic study did not consider PAD.
Fleischhackl, R., . "Reaching the public via a multi media campaign as a first step to nationwide public access defibrillation." Resuscitation 69(2): 269-75.
Reviewer's Comment: This paper describes a public campaign to increase the number of PAD programs across Austria this is relevant but not directly related to this worksheet. Two additional references were identified.
Folke, F., F. K. . "Location of cardiac arrest in a city center: strategic placement of automated external defibrillators in public locations." Circulation 120(6): 510-7.
Reviewer's Comment: Relevant to the worksheet but does not directly address the worksheet question. of 20 Reviewer's Comments: A sub-study of the PAD trial looking at skill retention among volunteers. Does not answer the worksheet question but is relevant. . "The use of AEDs by police officers in the City of London. Automated external defibrillators." Resuscitation 50(2): 141-6.

## Reviewer's comments:
This article is relevant to the worksheet question, however because it does not address response outside the EMS system it is not considered evidence in the evaluation. Further, it does not compare outcomes and only services to illustrate that a police AED program is feasible.
Sayre, M. R., . "Measuring survival rates from sudden cardiac arrest: the elusive definition." Resuscitation 62(1): 25-34.

## Reviewer's comment:
This was a sub-analysis of the PAD trial, looking at the effect of changing definitions on the study outcome. It was not included as evidence since it is already represented by the Hallstrom paper. van Alem, A. P., . "Use of automated external defibrillator by first responders in out of hospital cardiac arrest: prospective controlled trial." BMJ 327(7427): 1312.

## Reviewer's comments:
This article is relevant to the question but does not address PAD use outside of the EMS system. Wassertheil, J., . "Cardiac arrest outcomes at the Melbourne Cricket Ground and shrine of remembrance using a tiered response strategy-a forerunner to public access defibrillation." Resuscitation 44(2): 97-104.
Reviewer's Comment : This article is relevant to the worksheet question, however because it does not address response outside the EMS system it is not considered evidence in the evaluation. It examines AED use by ambulance service personnel at a mass gathering event.
Weaver, W. D., . "Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest." N Engl J Med 319(11): 661-6.
[fig] Fleischhackl: R.,B. Roessler, et al. (2008). "Results from Austria's nationwide public access defibrillation (ANPAD) programme collected over 2 years." Resuscitation 77(2): 195-200. [/fig]
[fig] Fedoruk: J. C., W. L. Currie, et al. (2002). "Locations of cardiac arrest: affirmation for community Public Access Defibrillation (PAD) Program." Prehosp Disaster Med 17(4): 202-5. Reviewer's Comment: This study looked at the locations of local cardiac arrests for the purpose of resource placement. It is relevant to the worksheet question but does not directly address the question. Finn, J. C., I. G. Jacobs, et al. (2001). "Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia, 1996-1999." Resuscitation 51(3): 247-55. [/fig]