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Rea T, Kudenchuk PJ, Sayre MR, Doll A, Eisenberg M. Out of hospital cardiac arrest: Past, present, and future. Resuscitation 2021; 165:101-109. [PMID: 34166740 DOI: 10.1016/j.resuscitation.2021.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/09/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
Advances in resuscitation following out-of-hospital cardiac arrest (OHCA) provide an opportunity to improve public health. This review reflects on past developments, present status, and future possibilities using the science-education-implementation framework of the Utstein Formula and the clinical framework of the links in the chain of survival. With the discovery of CPR and defibrillation in the mid 20th century, resuscitation developed a scientific construct for progress. Systems of emergency community response provided operational efficiency to treat OHCA. Contemporary resuscitation involves integrated interventions in the chain of survival: early recognition, early CPR, early defibrillation, expert and timely advanced life support and hospital care, and multidimensional rehabilitation. Implementation of scientific advances is especially challenging given the unexpected nature of OHCA, the need for time-sensitive interventions, and the substantial collective of stakeholders involved in the chain of survival. Systematic measurement provides the foundation to evaluate performance and guide implementation initiatives. For many systems, telecommunicator CPR and high-performance CPR by emergency professionals are accessible, near-term programs to improve OHCA outcome. Smart technologies that activate, coordinate, and/or coach community "volunteers" to accelerate early CPR and defibrillation have conceptual promise, though robust implementation has been achieved by only a handful of systems. Longer-term strategies may leverage technology to develop a high-fidelity "life-detector" or engineer and disseminate a specialized consumer defibrillator designed to bridge care until arrival of professional response.
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Affiliation(s)
- Thomas Rea
- Department of Medicine, University of Washington, United States
| | | | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, United States
| | - Ann Doll
- Resuscitation Academy, United States
| | - Mickey Eisenberg
- Department of Emergency Medicine, University of Washington, United States.
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2
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Salcido DD, Weiss LS. A glimpse of what could be. Resuscitation 2021; 162:431-432. [PMID: 33798625 DOI: 10.1016/j.resuscitation.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- David D Salcido
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Leonard S Weiss
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Haag MB, Hersh AR, Toffey DE, Sargent JA, Stecker EC, Heitner SB, Caughey AB, Balaji S. Cost-effectiveness of in-home automated external defibrillators for children with cardiac conditions associated with risk of sudden cardiac death. Heart Rhythm 2020; 17:1328-1334. [PMID: 32234558 DOI: 10.1016/j.hrthm.2020.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Children at high risk for sudden cardiac death (SCD) (>6% over 5 years) receive an implantable cardioverter-defibrillator (ICD), but no guidelines are available for those at lower risk. For children at intermediate risk for SCD (4%-6% over 5 years), the utility and cost-effectiveness of in-home automated external defibrillators (AEDs) are unclear. OBJECTIVE The purpose of this study was to assess the cost-effectiveness of in-home AED for children at intermediate risk for SCD. METHODS Using hypertrophic cardiomyopathy (HCM) as the proxy disease, a theoretical cohort of 1550 ten-year-old children with HCM was followed for 69 years. Baseline annual risk of SCD was 0.8%. Outcomes were SCD, severe neurologic morbidity (SNM), cost, and quality-adjusted life-years (QALYs). Model inputs were derived from the literature, with a willingness-to-pay threshold of $100,000 per QALY. RESULTS Among children at intermediate risk for SCD, in-home AED resulted in 31 fewer cases of SCD but 3 more cases of SNM. There were 319 QALYs gained. Although costs were higher by $28 million, the incremental cost-effectiveness ratio was $86,458, which is below the willingness-to-pay threshold. CONCLUSION For children at intermediate risk for SCD and HCM, in-home AED is cost-effective, resulting in fewer deaths and increased QALYS for a cost below the willingness-to-pay threshold. These findings highlight the economic benefits of in-home AED use in this population.
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Affiliation(s)
- Meredith B Haag
- Oregon Health and Science University, School of Medicine, Portland, Oregon
| | - Alyssa R Hersh
- Oregon Health and Science University, School of Medicine, Portland, Oregon
| | - David E Toffey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - James A Sargent
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Eric C Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Stephen B Heitner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Seshadri Balaji
- Doernbecher Children's Hospital, Division of Pediatric Cardiology, Oregon Health and Science University, Portland, Oregon.
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Malcom GE, Thompson TM, Coule PL. THELOCATION ANDINCIDENCE OFOUT-OF-HOSPITALCARDIACARREST INGEORGIA: IMPLICATIONS FORPLACEMENT OFAUTOMATEDEXTERNALDEFIBRILLATORS. PREHOSP EMERG CARE 2009; 8:10-4. [PMID: 14691781 DOI: 10.1080/312703002752] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Prior studies of automated external defrillator placement strategies for public access defibrillation (PAD) have addressed only the venue of out-of-hospital cardiac arrest (OOHCA) in large urban areas. This study evaluates the relationship between population density and the incidence and location of OOHCA. METHODS This study was a retrospective analysis of 624,199 Georgia state emergency medical services patient care reports (PCRs) in 2000. The PCR categorized these cardiac arrests by county into 12 location options. Counties were divided into population densities of <100, 100-400, 400-1,000, and >1,000 persons per square mile. The incidence of cardiac arrest for each location type was calculated for each population density group. RESULTS The <100 density group had only 21.77% of the state's population but 30.96% of the state's cardiac arrests, whereas the >1,000 density group had 35.46% of the population but only 23.55% of the cardiac arrests (p<0.0001). The relative risk (95% confidence interval) for OOHCA in the <100 density group compared with the >1,000 density group was 2.14 (2.00, 2.29). The percentage of OOHCAs that occurred in the home for each population density group was: <100 persons per square mile, (67.67%); 100-400 persons per square mile, (68.83%); 400-1,000 persons per square mile, (65.75%); and >1,000 persons per square mile (62.09%) (p=0.0001). CONCLUSIONS There are variations in incidence and location of OOHCA based on population density in Georgia. As population density increases, the incidence percentage of OOHCAs decreases. However, as population density increases, there is an increase in the percentage of cardiac arrests occurring outside the home, where more OOHCAs could potentially benefit from PAD.
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Norton KI, Norton LH. Automated external defibrillators in the Australian fitness industry. J Sci Med Sport 2008; 11:86-9. [PMID: 18272429 DOI: 10.1016/j.jsams.2007.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Revised: 12/18/2007] [Accepted: 12/21/2007] [Indexed: 10/22/2022]
Abstract
Sudden cardiac arrest (SCA) occurs in many thousands of Australians each year. Scientific evidence shows an increased survival rate for individuals who receive electrical defibrillation in the first few minutes after SCA. In the last decade automated (rhythm-detecting) external defibrillators (AEDs) have become available that are portable and affordable. Although still relatively rare, there is still the potential that SCA may occur when a person undertakes physical activity. Consequently, health/fitness centres are increasingly recognised as higher risk sites that may benefit from placement of AEDs. There are no laws in Australia requiring health/fitness centres to install AEDs. However, several international and professional organisations have "strongly encouraged" larger centres to install AEDs. Guidelines and algorithms are presented to help estimate the risk of SCA in fitness centres. Fitness centre placement is particularly important if the clientele is older or has a 'high-risk' profile, for example, clients with cardiovascular, respiratory or metabolic disease. International negligence case law and duty of care principles suggests the standard of care required in health/fitness centres may be increasing. Therefore, it may be prudent to install AEDs in larger centres and those in which higher risk groups are physically active.
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Cagle AJ, Diehr P, Meischke H, Rea T, Olsen J, Rodrigues D, Yakovlevitch M, Amidon T, Eisenberg M. Psychological and social impacts of automated external defibrillators (AEDs) in the home. Resuscitation 2007; 74:432-8. [PMID: 17395358 DOI: 10.1016/j.resuscitation.2007.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 01/17/2007] [Accepted: 01/17/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND The majority of cardiac arrests occur in the home. The placement of AEDs in the homes of at-risk patients may save lives through early defibrillation. However, the impact of having an AED in the home on psychological outcomes and quality-of-life is unknown. OBJECTIVE The purpose of this research was to determine whether training in the use of and possessing an automated external defibrillator (AED) has an effect on a patient at risk's quality of life. METHODS We investigated the psychological consequences of AED training and possession of such a device for patients who recently experienced an acute ischemic event. One hundred fifty eight patients and their family members were assigned at random to receive cardiopulmonary resuscitation (CPR) training (N=66) or AED/CPR training and possession of the device after training (N=92). We measured quality of life using the Short-Form (SF-36) survey and a 9-item survey we developed specifically for this study to measure differences in social activities and worries about being left alone. Participants answered these questions at enrollment, 2 weeks, 3 months, and 3 months after enrollment. RESULTS Patients in the AED group reported lower (worse) scores on most SF-36 subscales at all periods, particularly in those subscales relating to social functioning. The differences were most often small and probably not clinically meaningful. The social activities/worry scales also favored the CPR group at all periods, but with no significant differences. CONCLUSIONS Physicians counselling patients about AEDs should be aware of the potential effects the device may have on a patient's social functioning.
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Affiliation(s)
- Anthony J Cagle
- University of Washington School of Public Health and Community Medicine, Seattle, WA, USA.
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7
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Cram P, Katz D, Vijan S, Kent DM, Langa KM, Fendrick AM. Implantable or external defibrillators for individuals at increased risk of cardiac arrest: where cost-effectiveness hits fiscal reality. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2006; 9:292-302. [PMID: 16961547 DOI: 10.1111/j.1524-4733.2006.00118.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Implantable cardioverter defibrillators (ICDs) are highly effective at preventing cardiac arrest, but their availability is limited by high cost. Automated external defibrillators (AEDs) are likely to be less effective, but also less expensive. We used decision analysis to evaluate the clinical and economic trade-offs of AEDs, ICDs, and emergency medical services equipped with defibrillators (EMS-D) for reducing cardiac arrest mortality. METHODS A Markov model was developed to compare the cost-effectiveness of three strategies in adults meeting entry criteria for the MADIT II Trial: strategy 1, individuals experiencing cardiac arrest are treated by EMS-D; strategy 2, individuals experiencing cardiac arrest are treated with an in-home AED; and strategy 3, individuals receive a prophylactic ICD. The model was then used to quantify the aggregate societal benefit of these three strategies under the conditions of a constrained federal budget. RESULTS Compared with EMS-D, in-home AEDs produced a gain of 0.05 quality-adjusted life-years (QALYs) at an incremental cost of $5225 ($104,500 per QALY), while ICDs produced a gain of 0.90 QALYs at a cost of $114,660 ($127,400 per QALY). For every $1 million spent on defibrillators, 1.7 additional QALYs are produced by purchasing AEDs (9.6 QALYs/$million) instead of ICDs (7.9 QALYs/$million). Results were most sensitive to defibrillator complication rates and effectiveness, defibrillator cost, and adults' risk of cardiac arrest. CONCLUSIONS Both AEDs and ICDs reduce cardiac arrest mortality, but AEDs are significantly less expensive and less effective. If financial constraints were to lead to rationing of defibrillators, it might be preferable to provide more people with a less effective and less expensive intervention (in-home AEDs) instead of providing fewer people with a more effective and more costly intervention (ICDs).
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Affiliation(s)
- Peter Cram
- University of Iowa College of Medicine, Iowa City, IA, USA.
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Jones E, Vijan S, Fendrick AM, Deshpande S, Cram P. Automated external defibrillator deployment in high schools and senior centers. PREHOSP EMERG CARE 2006; 9:382-5. [PMID: 16263669 DOI: 10.1080/10903120500253847] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Policymakers with limited funds have been forced to make difficult decisions regarding which sites merit automated external defibrillators (AEDs). Guidelines have recommended that the allocation of AEDs be based largely on the site-specific risk of sudden cardiac death (cardiac arrest), with devices preferentially located at high-risk venues. However, there are limited data on whether such a strategy is being followed. The authors surveyed low-risk (schools) and high-risk (senior centers) venues to assess the availability of AEDs. METHODS A random sample of 200 high schools was identified; 12 were excluded, resulting in a final sample of 188. Each was contacted to determine the number of students, number of teachers, availability of AEDs, and number of cardiac arrests during the 2001-02 academic year. For comparison, 20 licensed senior centers were surveyed to assess the availability of AEDs. RESULTS Among 147 schools that responded to the survey, the mean student enrollment was 1,117 and the mean number of teachers was 58. There were three reported cases of cardiac arrest (2 students, 1 teacher), resulting in an annual incidence of cardiac arrest in a school of 2.1% (95% confidence interval [CI] 0.4%-5.7%). Thirty-seven schools (25%; 95% CI 18%-33%) reported having AEDs and 35 (27%) intended to purchase them. In contrast, among 20 senior centers, AEDs were available at two (10%; 95% CI 1%-32%), and the and there were four reported cardiac arrests (annual incidence 20%). CONCLUSION The availability of AEDs across different sites may not correspond directly to the risk of cardiac arrest at these sites.
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Affiliation(s)
- Elizabeth Jones
- Iowa City Veterans Affairs Medical, Center, Division of General Medicine, Department of Internal, Medicine, University of Iowa College of Medicine, Iowa City, Iowa 52242, USA
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9
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Cost-effectiveness of in-home automated external defibrillators for individuals at increased risk of sudden cardiac death. J Gen Intern Med 2005; 20:251-8. [PMID: 15836529 PMCID: PMC1490077 DOI: 10.1111/j.1525-1497.2005.40247.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE In-home automated external defibrillators (AEDs) are increasingly recommended as a means for improving survival of cardiac arrests that occur at home. The current study was conducted to explore the relationship between individuals' risk of cardiac arrest and cost-effectiveness of in-home AED deployment. DESIGN Markov decision model employing a societal perspective. PATIENTS Four hypothetical cohorts of American adults 60 years of age at progressively greater risk for sudden cardiac death (SCD): 1) all adults (annual probability of SCD 0.4%); 2) adults with multiple SCD risk factors (probability 2%); 3) adults with previous myocardial infarction (probability 4%); and 4) adults with ischemic cardiomyopathy unable to receive an implantable defibrillator (probability 6%). INTERVENTION Strategy 1: individuals suffering an in-home cardiac arrest were treated with emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals suffering an in-home cardiac arrest received initial treatment with an in-home AED, followed by EMS. RESULTS Assuming cardiac arrest survival rates of 15% with EMS-D and 30% with AEDs, the cost per quality-adjusted life-year gained (QALY) of providing in-home AEDs to all adults 60 years of age is 216,000 dollars. Costs of providing in-home AEDs to adults with multiple risk factors (2% probability of SCD), previous myocardial infarction (4% probability), and ischemic cardiomyopathy (6% probability) are 132,000 dollars, 104,000 dollars, and 88,000 dollars, respectively. CONCLUSIONS The cost-effectiveness of in-home AEDs is intimately linked to individuals' risk of SCD. However, providing in-home AEDs to all adults over age 60 appears relatively expensive.
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Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M, Eisenberg MS, Copass MK. Public Access Defibrillation in Out-of-Hospital Cardiac Arrest. Circulation 2004; 109:1859-63. [PMID: 15023881 DOI: 10.1161/01.cir.0000124721.83385.b2] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The dissemination and use of automated external defibrillators (AEDs) beyond traditional emergency medical services (EMS) into the community has not been fully evaluated. We evaluated the frequency and outcome of non-EMS AED use in a community experience. METHODS AND RESULTS The investigation was a cohort study of out-of-hospital cardiac arrest cases due to underlying heart disease treated by public access defibrillation (PAD) between January 1, 1999, and December 31, 2002, in Seattle and surrounding King County, Washington. Public access defibrillation was defined as out-of-hospital cardiac arrest treated with AED application by persons outside traditional emergency medical services. The EMS of Seattle and King County developed a voluntary Community Responder AED Program and registry of PAD AEDs. During the 4 years, 475 AEDs were placed in a variety of settings, and more than 4000 persons were trained in cardiopulmonary resuscitation and AED operation. A total of 50 cases of out-of-hospital cardiac arrest were treated by PAD before EMS arrival, which represented 1.33% (50/3754) of all EMS-treated cardiac arrests. The proportion treated by PAD AED increased each year, from 0.82% in 1999 to 1.12% in 2000, 1.41% in 2001, and 2.05% in 2002 (P=0.019, test for trend). Half of the 50 persons treated with PAD survived to hospital discharge, with similar survival for nonmedical settings (45% [14/31]) and out-of-hospital medical settings (58% [11/19]). CONCLUSIONS PAD was involved in only a small but increasing proportion of out-of-hospital cardiac arrests.
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Affiliation(s)
- Linda L Culley
- Public Health Seattle and King County, Emergency Medical Services Division, 999 Third Ave, Suite 700, Seattle, WA 98104-4039, USA.
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11
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Straus SMJM, Bleumink GS, Dieleman JP, van der Lei J, Stricker BHC, Sturkenboom MCJM. The incidence of sudden cardiac death in the general population. J Clin Epidemiol 2004; 57:98-102. [PMID: 15019016 DOI: 10.1016/s0895-4356(03)00210-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES To determine the incidence of sudden cardiac death in a general (Dutch) population. METHODS Cohort study in the Integrated Primary Care Information (IPCI) project, a database with all medical data from 150 general practices in The Netherlands. The study population comprised 249,126 subjects with a mean follow-up of 2.54 years. RESULTS In this period 4,892 deaths were identified, 582 of which were classified as (probable) sudden cardiac death. The overall incidence of sudden cardiac death in this population was 0.92 cases per 1,000 person-years (95%CI: 0.85-0.99). The risk was 2.3-fold higher in men than in women, and increased with age. The incidence of sudden cardiac death peaked in October and was lowest in August. CONCLUSIONS The incidence of sudden cardiac death in the general Dutch population was almost 1 per 1,000 person-years per year during the period 1 January, 1995 to 1 April, 2001. Most of the cases occurred at home.
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Affiliation(s)
- S M J M Straus
- Department of Medical Informatics, Erasmus MC, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
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12
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Abstract
About one fifth of all deaths occur suddenly and unexpectedly, often as the first manifestation of heart disease. Several tests have been developed during the past 2 decades for risk stratification of such an event, but only a minority of victims can be identified as being at high risk before sudden death occurs. Improving the results of out-of-hospital resuscitation attempts is of crucial importance. Use of the automated external defibrillator is rapidly increasing worldwide. However, the defibrillator must be used within minutes after the onset of cardiac arrest, and rapid recognition and localization of the victim are essential. The development of a device that constantly monitors vital signs and can diagnose cardiac arrest, generate an alarm, and transmit the location of the victim could be an important step in improving the results of cardiac resuscitation.
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Affiliation(s)
- Hein J J Wellens
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands.
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Cram P, Vijan S, Fendrick AM. Cost-effectiveness of automated external defibrillator deployment in selected public locations. J Gen Intern Med 2003; 18:745-54. [PMID: 12950484 PMCID: PMC1494915 DOI: 10.1046/j.1525-1497.2003.21139.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates. DESIGN Markov Decision Model employing a societal perspective. SETTING Selected public locations in the United States. PATIENTS A simulated cohort of the American public. INTERVENTION Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival. RESULTS Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY. CONCLUSIONS AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.
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Affiliation(s)
- Peter Cram
- Division of General Medicine, Department of Internal Medicine, University of Iowa College of Medicine, 200 Hawkins Drive, 6SE GH, Iowa City, IA 52242, USA.
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Swor RA, Jackson RE, Compton S, Domeier R, Zalenski R, Honeycutt L, Kuhn GJ, Frederiksen S, Pascual RG. Cardiac arrest in private locations: different strategies are needed to improve outcome. Resuscitation 2003; 58:171-6. [PMID: 12909379 DOI: 10.1016/s0300-9572(03)00118-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND A tremendous amount of public resources are focused on improving cardiac arrest (OHCA) survival in public places, yet most OHCAs occur in private residences. METHODS AND RESULTS A prospective, observational study of patients transported to seven urban and suburban hospitals and the individuals who called 911 at the time of a cardiac arrest (bystander) was performed. Bystanders (N=543) were interviewed via telephone beginning 2 weeks after the incident to obtain data regarding patient and bystander demographics, including cardiopulmonary resuscitation (CPR) training. Of all arrests 80.2% were in homes. Patients who arrested in public places were significantly younger (63.2 vs. 67.2, P<0.02), more often had an initial rhythm of VF (63.0 vs. 37.7%, P<0.001), were seen or heard to have collapsed by a bystander (74.8 vs. 48.1%, P<0.001), received bystander CPR (60.2 vs. 28.6%, P<0.001), and survived to DC (17.5 vs. 5.5%, P<0.001). Patients who arrested at home were older and had an older bystander (55.4 vs. 41.3, P<0.001). The bystander was less likely to be CPR trained (65.0 vs. 47.4%, P<0.001), less likely to be trained within the last 5 years (49.2 vs. 17.9, P<0.001), and less likely to perform CPR if trained (64.2 vs. 30.0%, P<0.001). Collapse to shock intervals for public versus home VF patients were not different. CONCLUSIONS Many important characteristics of cardiac arrest patients and the bystander differ in public versus private locations. Fundamentally different strategies are needed to improve survival from these events.
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Affiliation(s)
- Robert A Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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15
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Wellens HJJ, Gorgels AP, de Munter H. Cardiac arrest outside of a hospital: how can we improve results of resuscitation? Circulation 2003; 107:1948-50. [PMID: 12707248 DOI: 10.1161/01.cir.0000067880.57844.62] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rea TD, Eisenberg MS, Becker LJ, Lima AR, Fahrenbruch CE, Copass MK, Cobb LA. Emergency medical services and mortality from heart disease: a community study. Ann Emerg Med 2003; 41:494-9. [PMID: 12658249 DOI: 10.1067/mem.2003.149] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVES Little is known regarding the potential effects of emergency medical services (EMS) on total heart disease mortality. Although EMS may provide health benefits in less acute cardiac conditions, its immediate, measurable, and direct effect on heart disease mortality is through resuscitation of persons suffering out-of-hospital cardiac arrest. The purpose of this study was to examine the involvement and potential mortality benefit of out-of-hospital EMS care of cardiac arrest on community heart disease mortality. METHODS The investigation was an observational study of all persons with death events resulting from heart disease as defined by heart disease deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in a single county from January 1, 2000, through December 31, 2000. The county of study has a population of nearly 2 million people and is composed of urban, suburban, and rural components. State vital records and EMS reports were used to ascertain deaths resulting from heart disease and deaths averted. RESULTS In the year 2000, 3,577 persons died as a result of heart disease, and 128 persons were successfully resuscitated and discharged from the hospital, for a total of 3,705 death events. EMS responded to 39% (1,428/3,705) of all heart disease death events and 57% (1,428/2,516) of out-of-hospital events, resulting in a 3.5% (128/3,705) reduction in overall heart disease mortality and a 5.1% (128/2,516) reduction in out-of-hospital mortality. CONCLUSION EMS was involved in the majority of out-of-hospital heart disease death events, resulting in a measurable reduction in heart disease mortality.
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Affiliation(s)
- Thomas D Rea
- Department of Medicine, University of Washington, Seattle, WA, USA.
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17
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Abstract
BACKGROUND Automated external defibrillators save lives when they are used by designated personnel in certain public settings. We performed a two-year prospective study at three Chicago airports to assess whether random bystanders witnessing out-of-hospital cardiac arrests would retrieve and successfully use automated external defibrillators. METHODS Defibrillators were installed a brisk 60-to-90-second walk apart throughout passenger terminals at O'Hare, Midway, and Meigs Field airports, which together serve more than 100 million passengers per year. The use of defibrillators was promoted by public-service videos in waiting areas, pamphlets, and reports in the media. We assessed the time from notification of the dispatchers to defibrillation, survival rate at 72 hours and at one year among persons with cardiac arrest, their neurologic status, and the characteristics of rescuers. RESULTS Over a two-year period, 21 persons had nontraumatic cardiac arrest, 18 of whom had ventricular fibrillation. With two exceptions, defibrillator operators were good Samaritans, acting voluntarily. In the case of four patients with ventricular fibrillation, defibrillators were neither nearby nor used within five minutes, and none of these patients survived. Three others remained in fibrillation and eventually died, despite the rapid use of a defibrillator (within five minutes). Eleven patients with ventricular fibrillation were successfully resuscitated, including eight who regained consciousness before hospital admission. No shock was delivered in four cases of suspected cardiac arrest, and the device correctly indicated that the problem was not due to ventricular fibrillation. The rescuers of 6 of the 11 successfully resuscitated patients had no training or experience in the use of automated defibrillators, although 3 had medical degrees. Ten of the 18 patients with ventricular fibrillation were alive and neurologically intact at one year. CONCLUSIONS Automated external defibrillators deployed in readily accessible, well-marked public areas in Chicago airports were used effectively to assist patients with cardiac arrest. In the cases of survivors, most of the users had no duty to act and no prior training in the use of these devices.
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Affiliation(s)
- Sherry L Caffrey
- City of Chicago Department of Aviation, O'Hare International Airport, Chicago, IL 60666, USA.
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Chen MA, Eisenberg MS, Meischke H. Impact of in-home defibrillators on postmyocardial infarction patients and their significant others: an interview study. Heart Lung 2002; 31:173-85. [PMID: 12011808 DOI: 10.1067/mhl.2002.124344] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the impact of automated external defibrillator (AED) placement in the homes of postmyocardial infarction (MI) patients and their significant others. DESIGN This qualitative study used a semistructured interview to examine a nonrandomized convenience sample recruited from a larger study of home AEDs. SETTING AND PARTICIPANTS Patients (and their significant others) were recruited from an ongoing study of AED use in the home. Seventeen interviews with 15 patients (14 men, 1 woman) and 16 significant others (1 man, 15 women) aged 39 to 80 years were performed in patients' homes. METHODS Verbatim transcripts of audiotaped interviews were reviewed, and responses were categorized. Other data were obtained from hospital chart abstraction. RESULTS The majority of subjects noted only positive effects of the presence of home AEDs (eg, giving them feelings of security and control). There was no evidence that AED presence in the home caused excessive anxiety or stress either in patients or their significant others, nor were they perceived to cause relationship stress. On average, patients and their significant others estimated a 38% and 43% (respectively) risk of cardiac arrest and a 92% and 87% likelihood of a successful resuscitation with the use of the AED. Subjects' perceived risk of cardiac arrest were subjectively related to their estimate of current health status, size of infarction, and symptoms during their MI. Subjects also related their estimates of risk to their likelihood of traveling with their AED and whether they would consider purchasing one. Significant others had high confidence in their ability to properly use the AED. CONCLUSIONS AEDs were valued highly by subjects and enhanced their perceived control over their heart disease. This was especially true for subjects who believed that their risk of cardiac arrest was high. The possible effects of providing education regarding expert estimates of the likelihood of cardiac arrest and of a successful resuscitation at the time of AED placement are discussed.
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Affiliation(s)
- Michael A Chen
- Department of Internal Medicine, Division of Health Services, University of Washington Hospitals, 9008 30th Avenue NE, Seattle, WA 98115, USA
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19
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Meischke HW, Rea TD, Eisenberg MS, Rowe SM. Intentions to use an automated external defibrillator during a cardiac emergency among a group of seniors trained in its operation. Heart Lung 2002; 31:25-9. [PMID: 11805746 DOI: 10.1067/mhl.2002.119833] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE By decreasing the time to defibrillation, automated external defibrillators (AEDs) provide an opportunity for lay people to improve survival in out-of-hospital sudden cardiac arrest. We examined how beliefs, expectations, and actual performance are related to intentions to use an AED during a future heart emergency among a group of seniors. DESIGN AND OUTCOME MEASURES One hundred fifty-nine seniors who had been previously trained in the operation of an AED were tested on their AED skills and asked about their perceptions regarding their AED skills; their expectations that an AED would save the life of a cardiac arrest victim; and their intentions to use an AED during a future cardiac event. RESULTS Logistic regression analyses showed that greater self-perceived ability to use an AED better actual performance on skills assessment but not expectations regarding the efficacy of AED treatment were independently associated with positive intentions to use an AED in a future heart emergency. CONCLUSIONS The likelihood that an elderly lay bystander will actually use an AED during a cardiac event may be closely tied to perceptions of his or her ability to operate an AED.
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White RD. Technologic advances and program initiatives in public access defibrillation using automated external defibrillators. Curr Opin Crit Care 2001; 7:145-51. [PMID: 11436520 DOI: 10.1097/00075198-200106000-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Widespread provision of early defibrillation following cardiac arrest holds major promise for improved survival from ventricular fibrillation. The critical element in predicting a successful outcome is the rapidity with which defibrillation is achieved. A worldwide awareness of this potential and its advocacy by such organizations as the American Heart Association have been pivotal in the evolution of initiatives to make defibrillation more widely and more rapidly available. The feasibility of this initiative, known as public access defibrillation, is in large measure a direct consequence of major technologic advances in automated external defibrillators (AEDs). New low-energy waveforms with biphasic morphology have been shown to be more effective in terminating ventricular fibrillation and may do so with less myocardial injury. Placement of AEDs in a variety of nontraditional settings such as police cars, aircraft and airport terminals, and gambling casinos has been shown to yield an impressive number of survivors of cardiac arrest in ventricular fibrillation. Questions yet to be answered center on the appropriate disposition of AEDs in public access defibrillation settings, training and retraining issues, device maintenance, and collection of accurate data to document benefit and to identify areas of needed improvement or expansion of AED availability.
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Affiliation(s)
- R D White
- Department of Anesthesiology, Mayo Medical School and Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Sandison T, Meischke HW, Schaeffer SM, Eisenberg MS. Barriers and facilitators to the prescription of automated external defibrillators for home use in patients with heart disease: a survey of cardiologists. Heart Lung 2001; 30:210-5. [PMID: 11343007 DOI: 10.1067/mhl.2001.115084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Because the majority of cardiac arrests occur at home, the use of automated external defibrillators (AEDs) in the home could potentially improve survival of out-of-hospital cardiac arrest. Currently, physicians must prescribe AEDs for home use by patients. The purpose of this study was to investigate the barriers and facilitators to prescription of home use of AEDs. DESIGN Telephone interviews were conducted with 85 cardiologists and paper and pencil surveys (via fax) with 59 additional cardiologists in Washington State. OUTCOME MEASURES Cardiologists were asked about their current practices and their perceived barriers and facilitators to prescription of AEDs for home use. RESULTS Eighty-five percent of the sample believed that AEDs could be effective in preventing death, although only 7% of the cardiologists had ever prescribed an AED. Reasons for nonprescription included the use of implantable cardioverter defibrillators, perceived lack of a clear patient niche, and lack of knowledge about the device. The majority of respondents reported that they would be more likely to prescribe AEDs if they were the standard of care (71%), were covered by insurance (67%), and came with comprehensive training (58%). CONCLUSION The results showed that cardiologists believe that home use of AEDs can be effective but that many issues regarding the prescription of AEDs remain.
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Affiliation(s)
- T Sandison
- School of Medicine, the Department of Health Services, University of Washington, USA
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Affiliation(s)
- M S Eisenberg
- Department of Medicine, University of Washington, Seattle, USA.
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Rosen KR, Sinz EH, Casto J. Basic and advanced life support, acute resuscitation, and cardiac resuscitation. Curr Opin Anaesthesiol 2001; 14:177-84. [PMID: 17016399 DOI: 10.1097/00001503-200104000-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The global approach to resuscitation has changed dramatically in the past year. The groundwork for these changes began a decade ago with the development of the Utstein guidelines for uniform reporting of critical events. Consistency in data collection was necessary to enable evidence-based review and comparison of current practice. Resuscitation protocols have been significantly altered based upon these data. Basic life support (BLS) protocols have been simplified. Early access to electrical cardioversion is the key to survival. Mobilization of AED technology in the community is essential. Several issues were identified as crucial to future improvement of resuscitation statistics. Prevention strategies should be developed for high-risk patients. There is a need to identify cases in which resuscitation should not be started. Enhancement of educational methods to improve performance and retention of skills is key. Finally, the roadblocks for performance of ethical prospective research must be minimized.
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Affiliation(s)
- K R Rosen
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia 26506-9134, USA.
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