Public access defibrillation: time to access the public

Investigating Users' Attitudes Toward Automated Smartwatch Cardiac Arrest Detection: Cross-Sectional Survey Study

Background

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality in the developed world. Timely detection of cardiac arrest and prompt activation of emergency medical services (EMS) are essential, yet challenging. Automated cardiac arrest detection using sensor signals from smartwatches has the potential to shorten the interval between cardiac arrest and activation of EMS, thereby increasing the likelihood of survival.

Objective

This cross-sectional survey study aims to investigate users' perspectives on aspects of continuous monitoring such as privacy and data protection, as well as other implications, and to collect insights into their attitudes toward the technology.

Methods

We conducted a cross-sectional web-based survey in the Netherlands among 2 groups of potential users of automated cardiac arrest technology: consumers who already own a smartwatch and patients at risk of cardiac arrest. Surveys primarily consisted of closed-ended questions with some additional open-ended questions to provide supplementary insight. The quantitative data were analyzed descriptively, and a content analysis of the open-ended questions was conducted.

Results

In the consumer group (n=1005), 90.2% (n=906; 95% CI 88.1%-91.9%) of participants expressed an interest in the technology, and 89% (n=1196; 95% CI 87.3%-90.7%) of the patient group (n=1344) showed interest. More than 75% (consumer group: n= 756; patient group: n=1004) of the participants in both groups indicated they were willing to use the technology. The main concerns raised by participants regarding the technology included privacy, data protection, reliability, and accessibility.

Conclusions

The vast majority of potential users expressed a strong interest in and positive attitude toward automated cardiac arrest detection using smartwatch technology. However, a number of concerns were identified, which should be addressed in the development and implementation process to optimize acceptance and effectiveness of the technology.

Factors and Barriers on Cardiopulmonary Resuscitation and Automated External Defibrillator Willingness to Use among the Community: A 2016-2021 Systematic Review and Data Synthesis

Background

Bystander cardiopulmonary resuscitation (CPR) and using an automated external defibrillator (AED) can improve out-of-hospital cardiac arrest survival. However, bystander CPR and AED rates remained consistently low. The goal of this systematic review was to assess factors influencing community willingness to perform CPR and use an AED for out-of-hospital cardiac arrest survival (OHCA) victims, as well as its barriers.

Methods

The review processes (PROSPERO: CRD42021257851) were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review protocol; formulation of review questions; systematic search strategy based on identification, screening, and eligibility using established databases including Scopus, Web of Science, and Medline Complete via EBSCOhost; quality appraisal; and data extraction and analysis. There is identification of full-text journal articles that were published between 2016 and 2021 and written in English.

Results

Of the final 13 articles, there are six identified factors associated with willingness to perform CPR and use an AED, including socio-demographics, training, attitudes, perceived norms, self-efficacy, and legal obligation. Younger age, men, higher level of education, employed, married, having trained in CPR and AED in the previous 5 years, having received CPR education on four or more occasions, having a positive attitude and perception toward CPR and AED, having confidence to perform CPR and to apply an AED, and legal liability protection under emergency medical service law were reasons why one would be more likely to indicate a willingness to perform CPR and use an AED. The most reported barriers were fear of litigation and injuring a victim.

Conclusions

There is a need to empower all the contributing factors and reduce the barrier by emphasizing the importance of CPR and AEDs. The role played by all stakeholders should be strengthened to ensure the success of intervention programs, and indirectly, that can reduce morbidity and mortality among the community from OHCA.

Assessing the weak links - Necessity and impact of regional cardiac arrest awareness campaigns for laypersons

Introduction

Public knowledge of out-of-hospital cardiac arrest (OHCA), and initiation of basic life support (BLS) is crucial to increase survival in OHCA.

Methods

The study analysed the knowledge and willingness to perform BLS of laypersons passing an AED at a public train station. Interviewees were recruited at two time points before and after a four year-long structured regional awareness campaign, which focused on call, compress, shock in a mid-size European city (270,000 inhabitants). Complete BLS was defined as multiple responses for call for help; initiation of chest compressions; and usage of an AED, without mentioning recovery position. Minimal BLS was defined as call for help and initiation of chest compressions.

Results

A total of 784 persons were interviewed, 257 at baseline and 527 post-campaign. Confronted with a fictional OHCA, at baseline 8.5% of the interviewees spontaneously mentioned actions for complete BLS and 17.9% post-campaign (p = 0.009). An even larger increase in knowledge was seen in minimal BLS (34.6% vs 60.6%, p < 0.001).

Conclusion

After a regional cardiac arrest awareness campaign, we found an increase in knowledge of BLS actions in the lay public. However, our investigation revealed severe gaps in BLS knowledge, possibly resulting in weak first links of the chain of survival.

Sudden Cardiac Arrest in Basketball and Soccer Stadiums, the Role of Automated External Defibrillators: A Review. For the BELTRAN Study (BaskEtbaLl and soccer sTadiums: Registry on Automatic exterNal defibrillators)

Sudden cardiac arrest (SCA) during sports events has a dramatic impact on stadium-goers and the public and is often associated with poor outcomes unless treated with an automated external defibrillator (AED). Despite this, stadiums vary in AED use. This review aims to identify the risks and incidences of SCA, and the use of AEDs in soccer and basketball stadiums. A narrative review of all relevant papers was conducted. Athletes across all sports face an SCA risk of 1:50,000 athlete-years, with the greatest risk of SCA in young male athletes (1:35,000 person-years) and black male athletes (1:18,000 person-years). Africa and South America have the poorest soccer SCA outcomes at 3% and 4% survival. AED use on-site improves survival greater than defibrillation by emergency services. Many stadiums do not have AEDs implemented into medical plans and the AEDs are often unrecognisable or are obstructed. Therefore, AEDs should be used on-site, use clear signalling, have certified trained personnel, and be incorporated into stadiums' medical plans.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

Public awareness and willingness to use automated external defibrillators in a metropolitan city

Objective

Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys.

Methods

Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs.

Results

Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10–1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43–2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13–1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26–5.93).

Conclusion

To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

Barriers to bystanders defibrillation: A national survey on public awareness and willingness of bystanders defibrillation☆

BACKGROUND

After years of setting up public automated external defibrillators (AEDs), the rate of bystander AED use remains low all over the world. This study aimed to assess the public awareness and willingness of bystanders to use AEDs and to investigate the awareness on the Good Samaritan Law (GSL) and the factors associated with the low rate of bystander AED use.

METHODS

Using stratified random sampling, national telephone interviews were conducted using an author-designed structured questionnaire. The results were weighted to match the census data in Taiwan. The factors associated with public awareness and willingness of bystanders to use AEDs were analysed by logistic regression.

RESULTS

Of the 1073 respondents, only 15.2% had the confidence to recognise public AEDs, and 5.3% of them had the confidence to use the AED. Concerns on immature technique and legal issues remain the most common barriers to AED use by bystanders. Moreover, only 30.8% thought that the public should use AEDs at the scene. Few respondents (9.6%) ever heard of the GSL in Taiwan, and less than 3% understood the meaning of GSL. Positive awareness on AEDs was associated with high willingness of bystanders to use AEDs. Respondents who were less likely to use AEDs as bystanders were healthcare personnel and women.

CONCLUSION

The importance of active awareness and the barriers to the use of AEDs among bystanders seemed to have been underestimated in the past years. The relatively low willingness to use AEDs among bystander healthcare providers and women needs further investigation.

Are Irish Gaelic Athletic Association clubs prepared to use an AED following a sudden cardiac arrest? A cross-sectional survey

Objectives: To identify the availability and accessibility of AEDs in Irish GAA clubs and the knowledge, willingness, and confidence of club members to use AEDs in a medical emergency. Methods: A self-report survey was completed anonymously by GAA club members (n = 267). The survey captured demographic information, previous formal AED training, awareness of AED access in their local GAA club and knowledge, confidence, and willingness to use an AED in a medical emergency and awareness of a written club emergency action plan (EAP). Descriptive statistics were used to examine survey responses and independent samples t-tests to compare differences in outcome scores between those who have or have not completed formal AED training and those that have or have not studied toward or worked in a health-care provision role. Results: Three in every five GAA club members reported that their club owned an AED and almost half of all respondents had access to a club AED in the event of a medical emergency in their club. Formal training was noted by 53.2% of respondents; this group demonstrated significantly better knowledge, confidence, and willingness (p < 0.0001) than those without. Few (7%) respondents knew where the club EAP was or how to access it. Conclusion: To ensure the chain of survival works effectively it is essential that an AED is available, is accessible, and that club members know its location, know when to use it, and are willing and confident to use it. GAA clubs should design an individual emergency action plan and disseminate it widely among club members. Formal AED training should be encouraged among club members and at least one trained member should be present during all club activities.

The use of an automatic defibrillator by non-sanitary personnel in sport areas: an Observational Study

Introduction:

In industrialized countries, sudden cardiac death is a serious public health problem that accounts for about 15% to 20% of all deaths, with an incidence of 0.5 to 3 deaths per 100,000 athletes. In recent years, although both first aid prevention programs and the availability of External Automatic Defibrillator (AED) in public places have increased, few data are available with respect to real knowledge about the use of such devices. The aim of this study is to detect the level of knowledge and skills in the use of automatic external defibrillators among sports and management staff in sports facilities.

Materials and Methods:

A cross-sectional, multicentre study conducted in 16 sports facilities in the Province of Lecce, Italy, and targeted to all the athletic and managerial staff of these sports facilities. Information was obtained through a validated questionnaire consisting of 27 items.

Results:

339 participants of which 59.3% male (n=201) (average=33.6; SD=13.1). 51.6% (n=175) were informed about the presence of the defibrillator, only 38.1% (n=129) declared to know where it was placed and 43.7% (n=96) considered it to be quite or very accessible. The majority of them (78.8%; n=267) were never involved in a training course and declared limited knowledge about the use of this device.

Conclusions:

Respondents stated that they have poor knowledge and skills in the use of the defibrillator, its operation and maintenance, which could reduce the positive outcomes of early treatment. Further studies should be conducted, although it may be appropriate to implement specific training courses for personnel working in sports centres. (www.actabiomedica.it)

Implementing automated external defibrillators into community sports clubs/facilities: a cross-sectional survey of community club member preparedness for medical emergencies

Objective

There is a growing focus on ensuring the availability of automated external defibrillators (AED) in sport settings to assist in preventing sudden cardiac death. For the AED to be most effective, understanding how best to integrate it with wider risk management and emergency action plans (EAP) is needed. The aim of this survey was to identify sports club/facility member knowledge of AED use and club EAPs, 6 months following participation in a government-funded AED provision and cardiopulmonary resuscitation training programme.

Methods

Cross-sectional survey of community sports clubs and facilities in Victoria, Australia. Included participants were members of sports club/facilities that had been provided with an AED and basic first aid training as part of a government programme to increase access to, and awareness of, AEDs. A descriptive analysis of availability of EAPs and AEDs, together with practical scenarios on AED use and maintenance, is presented.

Results

From 191 respondents, more than half (56%) had no previous training in AED use. Knowledge on availability of an EAP at the club/facility was varied: 53% said yes and knew where it was located, while 41% did not have, or did not know if they had, an EAP. Responses to clinical scenarios for use of AED were mostly accurate, with the exception of being unsure how to respond when ‘a participant falls to the ground and is making shaking movements.’

Conclusions

While there were positive outcomes from this programme, such as half of the respondents being newly trained in emergency first aid response, further improvements are required to assist members with embedding their AED into their club/facility EAP and practices.

A community intervention study on patients' resuscitation and defibrillation quality after embedded training in a cardiac rehabilitation program

The aim of this study was to examine the effectiveness of a novel cardiopulmonary resuscitation (CPR) training method embedded in a cardiac rehabilitation program at enhancing patients' CPR and defibrillation skills. One hundred and fourteen participants with coronary heart disease enrolled on an exercise-based cardiac rehabilitation program were included. Two groups were randomly allocated to different training programs: CPR-retraining based on hands-on rolling refreshers during the 2-month program (G-CPR, n = 53) versus standard one-time training (G-Stan, n = 61). Resuscitation and defibrillation skills and self-confidence were evaluated at baseline, following brief basic life support (BLS) instruction and after the distinct training programs. Baseline skills were equally poor, improving significantly although irregularly after brief instruction. After the program, CPR quality was further enhanced in G-CPR, which achieved better results regarding correct compressions by depth, rate, hands position and global CPR quality (P < 0.01, all analysis). Defibrillation skills improved similarly after instruction and were reasonably maintained after the program, although delay to shock was reduced in G-CPR. CPR self-confidence was superior in G-CPR (P < 0.001). In conclusion, CPR hands-on rolling refreshers embedded into an exercise-based cardiac rehabilitation program enhanced patients' CPR and defibrillation skills and self-confidence to perform CPR at 2 months, compared with standard one-time training. This method could help to bring effective training to high-risk populations.

Public knowledge and expectations about dispatcher assistance in out-of-hospital cardiac arrest

AIM

To assess the factors associated with the knowledge and expectations among the general public about dispatcher assistance in out-of-hospital cardiac arrest incidents.

BACKGROUND

In medical dispatch centres, emergency calls are frequently operated by specially trained nurses as dispatchers. In cardiac arrest incidents, efficient communication between the dispatcher and the caller is vital for prompt recognition and treatment of the cardiac arrest.

DESIGN

A cross-sectional observational survey containing six questions and seven demographic items.

METHOD

From January-June 2017 we conducted standardized interviews among 500 members of the general public in Norway. In addition to explorative statistical methods, we used multivariate logistic analysis.

RESULTS

Most participants expected cardiopulmonary resuscitation instructions, while few expected "help in deciding what to do." More than half regarded the bystanders present to be responsible for the decision to initiate cardiopulmonary resuscitation. Most participants were able to give the correct emergency medical telephone number. The majority knew that the emergency call would not be terminated until the ambulance arrived at the scene. However, only one-third knew that the emergency telephone number operator was a trained nurse.

CONCLUSION

The public expect cardiopulmonary resuscitation instructions from the emergency medical dispatcher. However, the majority assume it is the responsibility of the bystanders to make the decision to initiate cardiopulmonary resuscitation or not. Based on these findings, cardiopulmonary resuscitation training initiatives and public campaigns should focus more on the role of the emergency medical dispatcher as the team leader of the first resuscitation team in cardiac arrest incidents.

Gender and age-specific aspects of awareness and knowledge in basic life support

Background

The ‘chain of survival’—including early call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation—represents the most beneficial approach for favourable patient outcome after out-of-hospital cardiac arrest (OHCA). Despite increasing numbers of publicly accessible automated external defibrillators (AED) and interventions to increase public awareness for basic life support (BLS), the number of their use in real-life emergency situations remains low.

Methods

In this prospective population-based cross-sectional study, a total of 501 registered inhabitants of Vienna (Austria) were randomly approached via telephone calls between 08/2014 and 09/2014 and invited to answer a standardized questionnaire in order to identify public knowledge and awareness of BLS and AED-use.

Results

We found that more than 52 percent of participants would presume OHCA correctly and would properly initiate BLS attempts. Of alarming importance, only 33 percent reported that they would be willing to perform CPR and 50 percent would use an AED device. There was a significantly lower willingness to initiate BLS attempts (male: 40% vs. female: 25%; OR: 2.03 [95%CI: 1.39–2.98]; p<0.001) and to use an AED device (male: 58% vs. female: 44%; OR: 1.76 [95%CI: 1.26–2.53]; p = 0.002) in questioned female individuals compared to their male counterparts. Interestingly, we observed a strongly decreasing level of knowledge and willingness for BLS attempts (-14%; OR: 0.72 [95%CI: 0.57–0.92]; p = 0.027) and AED-use (-19%; OR: 0.68 [95%CI: 0.54–0.85]; p = 0.001) with increasing age.

Conclusion

We found an overall poor knowledge and awareness concerning BLS and the use of AEDs among the Viennese population. Both female and elderly participants reported the lowest willingness to perform BLS and use an AED in case of OHCA. Specially tailored programs to increase awareness and willingness among both the female and elderly community need to be considered for future educational interventions.

Public CPR and AED Knowledge: An Opportunity for Educational Outreach in South Carolina

OBJECTIVES

Sudden cardiac arrest (SCA) remains a significant cause of morbidity and mortality, and the key to increased survival is emergent bystander intervention. A growing body of evidence has shown that timely bystander-initiated cardiopulmonary resuscitation (CPR) and defibrillation are significantly correlated with an increased likelihood of survival. Despite these demonstrated benefits, bystanders perform these interventions in less than half of witnessed SCA cases. We hypothesized that the level of public CPR and automated external defibrillator (AED) knowledge may be limited and may play a role in the likelihood of intervening.

METHODS

A convenience survey of potential bystanders to SCA was conducted in a high-traffic shopping center to estimate the overall knowledge level of CPR and AED usage and determine general attitudes toward intervening in the setting of SCA. Concurrently with the survey, professional emergency responders offered free bystander compression-only CPR and AED training on location.

RESULTS

The majority of survey respondents expressed a willingness to perform the aforementioned interventions when asked directly. Results, however, indicate that although 69% of respondents consider themselves to have a general knowledge of CPR, only 18% spontaneously mentioned CPR when presented with a hypothetical SCA scenario. In addition, only 2.2% mentioned defibrillation, and 63% indicated that they would not know how to locate a public access AED when needed. Of the individuals who participated in both the survey and the training, all of them indicated that they were more likely to intervene in an SCA after receiving the training.

CONCLUSIONS

Our findings suggest that future public outreach efforts should target the current CPR and AED knowledge gap. They also indicate that free, brief trainings offered at public events are a feasible way to increase the knowledge and skills of potential bystanders to SCA.

Outcome Predictors of Patients in Out-Of-Hospital Cardiac Arrests with Pre-Hospital Defibrillation in Hong Kong

Objective

To report the epidemiology, outcomes and the predictors of survival in patients with out-of-hospital cardiac arrest (OHCA) with pre-hospital shockable cardiac rhythms in Hong Kong.

Methods

It was a prospective study based on data from the cardiac arrest registry of emergency departments (ED) in two regional hospitals in Hong Kong from 1st August 2010 to 31st January 2012. All non-traumatic patients aged 18 years or above presented with OHCA with shockable pre-hospital cardiac rhythm and received pre-hospital defibrillation were included. The characteristics of patients, pre-hospital data, management and outcomes were recorded in a standardised form compatible with Utstein template at the time of patient consultation. Binominal logistic regression was applied to evaluate the relationship between survival to admission (STA) and patients' variables.

Results

A total of 135 patients fulfilled the inclusion criteria. The mean age was 67.0 years old. The STA rate was 34.8% and the survival to discharge (STD) rate was 6.7%. Factors independently associated with better prognosis in terms of STA were presence of bystander cardiopulmonary resuscitation (CPR) (OR 5.76, 95% CI=1.08-30.5), restoration of spontaneous circulation (ROSC) before arrival to ED (OR 43.94, 95% CI= 4.19-460.43) and short time from calling emergency medical services (EMS) to first defibrillation (OR 0.82, 95% CI=0.70-0.96).

Conclusion

STA rate for adults presenting with shockable OHCA in our study was 34.8%. Patients with shockable OHCA with bystander CPR, short call-to-shock time and achieved ROSC before arrival to ED are significantly associated with higher STA rate.

Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review

Public access defibrillation initiatives make automated external defibrillators available to the public. This facilitates earlier defibrillation of out-of-hospital cardiac arrest victims and could save many lives. It is currently only used for a minority of cases. The aim of this systematic review was to identify barriers and facilitators to public access defibrillation. A comprehensive literature review was undertaken defining formal search terms for a systematic review of the literature in March 2017. Studies were included if they considered reasons affecting the likelihood of public access defibrillation and presented original data. An electronic search strategy was devised searching MEDLINE and EMBASE, supplemented by bibliography and related-article searches. Given the low-quality and observational nature of the majority of articles, a narrative review was performed. Sixty-four articles were identified in the initial literature search. An additional four unique articles were identified from the electronic search strategies. The following themes were identified related to public access defibrillation: knowledge and awareness; willingness to use; acquisition and maintenance; availability and accessibility; training issues; registration and regulation; medicolegal issues; emergency medical services dispatch-assisted use of automated external defibrillators; automated external defibrillator-locator systems; demographic factors; other behavioural factors. In conclusion, several barriers and facilitators to public access defibrillation deployment were identified. However, the evidence is of very low quality and there is not enough information to inform changes in practice. This is an area in urgent need of further high-quality research if public access defibrillation is to be increased and more lives saved. PROSPERO registration number CRD42016035543.

Automated External Defibrillators and Survival After Nonresidential Out of Hospital Cardiac Arrest in a Small North American City

Most studies demonstrate that the use of automated external defibrillators (AEDs) during out of hospital cardiac arrest is associated with survival, but the majority of these studies were performed in large cities. With this in mind, the aims of our study were to examine AED placement and variables associated with survival after nonresidential out of hospital cardiac arrest (NROHCA) in a small North American city. Cases of NROHCA and locations with AEDs, in Regina, between January 2010 and December 2014 were reviewed. Common locations for NROHCA were identified, the frequency of AED availability was determined, and the relations between survival and AED presence, bystander initiated cardiopulmonary resuscitation (CPR), or shockable rhythms were determined. Only 20% of cases of NROHCA had an AED present on the premise. The presence of an AED (p = 0.94) was not associated with survival to the emergency department, whereas bystander initiated CPR (p <0.01) and shockable rhythm (p <0.01) were associated with survival to the emergency department. The presence of an AED (p = 0.86) and bystander initiated CPR (p = 0.06) were not associated with survival to discharge from the hospital, whereas the presence of a shockable rhythm was (p <0.01). Multivariable logistic regression analysis demonstrated that the presence of a shockable rhythm was independently associated with survival to the emergency department (OR 11.78, p <0.01) and discharge from the hospital (OR 6.08, p <0.01). The optimal locations for AED placement in cities of similar size and density may need to be reexamined, as the findings may have implications for public policies surrounding AED placement.

Use of a geographic information system to identify differences in automated external defibrillator installation in urban areas with similar incidence of public out-of-hospital cardiac arrest: a retrospective registry-based study

OBJECTIVES

Early defibrillation in out-of-hospital cardiac arrest (OHCA) is of importance to improve survival. In many countries the number of automated external defibrillators (AEDs) is increasing, but the use is low. Guidelines suggest that AEDs should be installed in densely populated areas and in locations with many visitors. Attempts have been made to identify optimal AED locations based on the incidence of OHCA using geographical information systems (GIS), but often on small datasets and the studies are seldom reproduced. The aim of this paper is to investigate if the distribution of public AEDs follows the incident locations of public OHCAs in urban areas of Stockholm County, Sweden.

METHOD

OHCA data were obtained from the Swedish Register for Cardiopulmonary Resuscitation and AED data were obtained from the Swedish AED Register. Urban areas in Stockholm County were objectively classified according to the pan-European digital mapping tool, Urban Atlas (UA). Furthermore, we reclassified and divided the UA land cover data into three classes (residential, non-residential and other areas). GIS software was used to spatially join and relate public AED and OHCA data and perform computations on relations and distance.

RESULTS

Between 1 January 2012 and 31 December 2014 a total of 804 OHCAs occurred in public locations in Stockholm County and by December 2013 there were 1828 AEDs available. The incidence of public OHCAs was similar in residential (47.3%) and non-residential areas (43.4%). Fewer AEDs were present in residential areas than in non-residential areas (29.4% vs 68.8%). In residential areas the median distance between OHCAs and AEDs was significantly greater than in non-residential areas (288 m vs 188 m, p<0.001).

CONCLUSION

The majority of public OHCAs occurred in areas classified in UA as 'residential areas' with limited AED accessibility. These areas need to be targeted for AED installation and international guidelines need to take geographical location into account when suggesting locations for AED installation.

New signs to encourage the use of Automated External Defibrillators by the lay public

INTRODUCTION

Public Access Defibrillation - the use of Automated External Defibrillators (AEDs) by lay bystanders before the arrival of Emergency Medical Services - is an important strategy in delivering prompt defibrillation to victims of out-of-hospital cardiac arrest and can greatly improve survival rates. Such public-access AEDs are used rarely: one barrier might be poor understanding and content of current signage to indicate their presence. The aim of this project was to develop a sign, with public consultation, that better indicated the function of an AED, and an associated poster to encourage its use.

METHODS

Two public surveys were undertaken, in July and December 2015, to investigate perceptions of the current AED location sign recommended for use in the UK and to produce an improved location sign and associated information poster.

RESULTS

There were 1895 and 2115 respondents to the surveys. Fewer than half (47.9%, 895/1870) understood what the current location sign indicated. One of four design options for a location sign best explained the indication for (preferred by 56.0%, 1023/1828) and best encouraged the use of a public AED (51.8%, 946/1828). 83.5% (1766/2115) preferred an illustration of a stylised heart trace to the lightning bolt used at present. From five wording options, 'Defibrillator - Heart Restarter' was the most popular (29.4%, 622/2115). An associated poster was developed using design features from the new location sign, findings from the surveys and expert group input regarding its content.

CONCLUSIONS

This is the first time that public consultation has been used to design a public AED location sign. Effective signage has the potential to help break down the barriers to more widespread use of AEDs in public places.

Automated external defibrillation skills by naive schoolchildren

AIM

Early defibrillation should achieve the highest survival rates when applied within the first minutes after the collapse. Public access defibrillation programs have increased the population awareness of the importance of defibrillation. Schoolchildren should be trained in basic life support (BLS) skills and some countries have included BLS in their school syllabus. However, little is known of the current knowledge and ability of schoolchildren to use an automated external defibrillator (AED).

METHODS

A multicentric descriptive study, 1295 children from 6 to 16 years of age without previous BLS or AED training. Subjects performed a simulation with an AED and a manikin with no training or feedback and were evaluated by means of a checklist.

RESULTS

A total of 258 participants (19.9%) were able to simulate an effective and safe defibrillation in less than 3min and 52 (20.1% of this group) performed it successfully. A significant correlation between objective and age group was observed (G=0.172) (p<0.001). The average time to deliver a shock was 83.3±26.4s; that time decreased significantly with age [6 YO (108.3±40.4) vs. 16 YO (64.7±18.6)s] (p<0.001).

CONCLUSIONS

Around 20% of schoolchildren without prior training are able to use an AED correctly in less than 3min following the device's acoustic and visual instructions. However, only one-fifth of those who showed success managed to complete the procedure satisfactorily. These facts should be considered in order to provide a more accurate definition and effective implementation of BLS/AED teaching and training at schools.

Public access defibrillation: improving accessibility and outcomes

BACKGROUND

Worldwide, out-of-hospital cardiac arrest (OHCA) remains a serious problem. Public access defibrillation (PAD) has been shown to be effective in improving survival in OHCA with good neurological outcome.

SOURCES OF DATA

Original articles, reviews and national/international guidelines.

AREAS OF AGREEMENT

Limitations to how much we can improve ambulance response times mean that the public have an essential role to play in OHCA survival. Training of laypersons in the use of automated external defibrillators (AEDs) has been shown to improve outcomes. Placement of AEDs should be related to underlying population demographics.

AREAS OF CONTROVERSY

Placements of AEDs face cost constraints. PAD programs also face challenges in the upkeep of AEDs. Concerns about legal liability for lay rescuers to act remain.

GROWING POINTS

Systematic programs should be in place to train the public in PAD. All AEDs should be listed in national registries and available for usage in an emergency.

AREAS TIMELY FOR DEVELOPING RESEARCH

'Smart' technology is being developed to improve accessibility of AEDs.

Sudden cardiac arrest during sports activity in middle age

BACKGROUND

Sports-associated sudden cardiac arrests (SCAs) occur mostly during middle age. We sought to determine the burden, characteristics, and outcomes of SCA during sports among middle-aged residents of a large US community.

METHODS AND RESULTS

Patients with SCA who were 35 to 65 years of age were identified in a large, prospective, population-based study (2002-2013), with systematic and comprehensive assessment of their lifetime medical history. Of the 1247 SCA cases, 63 (5%) occurred during sports activities at a mean age of 51.1±8.8 years, yielding an incidence of 21.7 (95% confidence interval, 8.1-35.4) per 1 million per year. The incidence varied significantly by sex, with a higher incidence among men (relative risk, 18.68; 95% confidence interval, 2.50-139.56) for sports SCAs compared with all other SCAs (relative risk 2.58; 95% confidence interval, 2.12-3.13). Sports SCA was also more likely to be a witnessed event (87% versus 53%; P<0.001) with cardiopulmonary resuscitation (44% versus 25%; P=0.001) and ventricular fibrillation (84% versus 51%; P<0.0001). Survival to hospital discharge was higher for sports-associated SCA (23.2% versus 13.6%; P=0.04). Sports SCA cases presented with known preexisting cardiac disease in 16% and ≥1 cardiovascular risk factors in 56%, and overall, 36% of cases had typical cardiovascular symptoms during the week preceding the SCA.

CONCLUSIONS

Sports-associated SCA in middle age represents a relatively small proportion of the overall SCA burden, reinforcing the idea of the high-benefit, low-risk nature of sports activity. Especially in light of current population aging trends, our findings emphasize that targeted education could maximize both safety and acceptance of sports activity in the older athlete.

Hidden in plain sight: a crowdsourced public art contest to make automated external defibrillators more visible

OBJECTIVES

We sought to explore the feasibility of using a crowdsourcing study to promote awareness about automated external defibrillators (AEDs) and their locations.

METHODS

The Defibrillator Design Challenge was an online initiative that asked the public to create educational designs that would enhance AED visibility, which took place over 8 weeks, from February 6, 2014, to April 6, 2014. Participants were encouraged to vote for AED designs and share designs on social media for points. Using a mixed-methods study design, we measured participant demographics and motivations, design characteristics, dissemination, and Web site engagement.

RESULTS

Over 8 weeks, there were 13 992 unique Web site visitors; 119 submitted designs and 2140 voted. The designs were shared 48 254 times on Facebook and Twitter. Most designers-voters reported that they participated to contribute to an important cause (44%) rather than to win money (0.8%). Design themes included: empowerment, location awareness, objects (e.g., wings, lightning, batteries, lifebuoys), and others.

CONCLUSIONS

The Defibrillator Design Challenge engaged a broad audience to generate AED designs and foster awareness. This project provides a framework for using design and contest architecture to promote health messages.

Defibrillation in the movies: a missed opportunity for public health education

AIM

To characterize defibrillation and cardiac arrest survival outcomes in movies.

METHODS

Movies from 2003 to 2012 with defibrillation scenes were reviewed for patient and rescuer characteristics, scene characteristics, defibrillation characteristics, additional interventions, and cardiac arrest survival outcomes. Resuscitation actions were compared with chain of survival actions and the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) 2020 Impact Goals. Cardiac arrest survival outcomes were compared with survival rates reported in the literature and targeted by the AHA ECC 2020 Impact Goals.

RESULTS

Thirty-five scenes were identified in 32 movies. Twenty-five (71%) patients were male, and 29 (83%) rescuers were male. Intent of defibrillation was resuscitation in 29 (83%) scenes and harm in 6 (17%) scenes. Cardiac arrest was the indication for use in 23 (66%) scenes, and the heart rhythm was made known in 18 scenes (51%). When the heart rhythm was known, defibrillation was appropriately used for ventricular tachycardia or ventricular fibrillation in 5 (28%) scenes and inappropriately used for asystole in 7 (39%) scenes. In 8 scenes with in-hospital cardiac arrest, 7 (88%) patients survived, compared to survival rates of 23.9% reported in the literature and 38% targeted by an AHA ECC 2020 Impact Goal. In 12 movie scenes with out-of-hospital cardiac arrest, 8 (67%) patients survived, compared to survival rates of 7.9-9.5% reported in peer-reviewed literature and 15.8% targeted by an AHA ECC 2020 Impact Goal.

CONCLUSION

In movies, defibrillation and cardiac arrest survival outcomes are often portrayed inaccurately, representing missed opportunities for public health education.

Public access defibrillation remains out of reach for most victims of out-of-hospital sudden cardiac arrest

INTRODUCTION

Public access defibrillation (PAD) prior to ambulance arrival is a key determinant of survival from out-of-hospital (OOH) cardiac arrest. Implementation of PAD has been underway in the UK for the past 12 years, and its importance in strengthening the chain of survival has been recognised in the government's recent 'Cardiovascular Disease Outcomes Strategy'. The extent of use of PAD in OOH cardiac arrests in the UK is unknown. We surveyed all OOH cardiac arrests in Hampshire over a 12-month period to ascertain the availability and effective use of PAD.

METHODS

A retrospective review of all patients with OOH cardiac arrest attended by South Central Ambulance Service (SCAS) in Hampshire during a 1-year period (1 September 2011 to 31 August 2012) was undertaken. Emergency calls were reviewed to establish the known presence of a PAD. Additionally, a review of all known PAD locations in Hampshire was undertaken, together with a survey of public areas where a PAD may be expected to be located.

RESULTS

The current population of Hampshire is estimated to be 1.76 million. During the study period, 673 known PADs were located in 278 Hampshire locations. Of all calls confirmed as cardiac arrest (n=1035), the caller reported access to an automated external defibrillator (AED) on 44 occasions (4.25%), successfully retrieving and using the AED before arrival of the ambulance on only 18 occasions (1.74%).

CONCLUSIONS

Despite several campaigns to raise public awareness and make PADs more available, many public areas have no recorded AED available, and in those where an AED was available it was only used in a minority of cases by members of the public before arrival of the ambulance. Overall, a PAD was only deployed successfully in 1.74% OOH cardiac arrests. This weak link in the chain of survival contributes to the poor survival rate from OOH cardiac arrest and needs strengthening.

How, when, and where have rental automated external defibrillators been used in Japan?

OBJECTIVE

Automated external defibrillators (AEDs) have been rented in various places in Japan. When rental AEDs are placed in locations where the probability of sudden cardiac arrest is high and permanent placement of AEDs is difficult, the possibility of improving survival rates might increase. In this preliminary study, we investigated how, when, and where rental AEDs have been used in Japan to clarify their characteristics when used in actual situations and to facilitate better usage in the future.

METHODS

We investigated the total number of AEDs rented, the duration of rental of each AED, the total number of AEDs rented monthly, the rental sites, the frequency and location of use, the number of defibrillations, and the time to defibrillation success for devices rented between January 2008 and December 2010 by a single company in Japan.

RESULTS

The number of AEDs rented annually was 590 at 391 sites in 2008, 767 at 465 sites in 2009, and 847 at 477 sites in 2010. More AEDs were rented during the summer. The devices were actually used on 17 individuals, of whom 2 individuals (at a beach and a marathon) underwent defibrillation, and 1 individual (at a marathon) survived.

CONCLUSION

Rental AEDs can play an important role in emergency cases occurring during seasonal and temporary outdoor events. The provision of rental AEDs in locations where permanent AEDs would be unfeasible may offer a useful strategy for efficiently improving survival rates in the future.

Where are lifesaving automated external defibrillators located and how hard is it to find them in a large urban city?

OBJECTIVES

Automated external defibrillators (AEDs) are lifesaving, but little is known about where they are located or how to find them. We sought to locate AEDs in high employment areas of Philadelphia and characterize the process of door-to-door surveying to identify these devices.

METHODS

Block groups representing approximately the top 3rd of total primary jobs in Philadelphia were identified using the US Census Local Employment Dynamics database. All buildings within these block groups were surveyed during regular working hours over six weeks during July-August 2011. Buildings were characterized as publically accessible or inaccessible. For accessible buildings, address, location type, and AED presence were collected. Total devices, location description and prior use were gathered in locations with AEDs. Process information (total people contacted, survey duration) was collected for all buildings.

RESULTS

Of 1420 buildings in 17 block groups, 949 (67%) were accessible, but most 834 (88%) did not have an AED. 283 AEDs were reported in 115 buildings (12%). 81 (29%) were validated through visualization and 68 (24%) through photo because employees often refused access. In buildings with AEDs, several employees (median 2; range 1-8) were contacted to ascertain information, which required several minutes (mean 4; range 1-55).

CONCLUSIONS

Door-to-door surveying is a feasible, but time-consuming method for identifying AEDs in high employment areas. Few buildings reported having AEDs and few permitted visualization, which raises concerns about AED access. To improve cardiac arrest outcomes, efforts are needed to improve the availability of AEDs, awareness of their location and access to them.

Assessment of knowledge and attitudes regarding automated external defibrillators and cardiopulmonary resuscitation among American University students

AIM

We sought to quantify knowledge and attitudes regarding automated external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR) among university students. We also aimed to determine awareness of the location of an actual AED on campus.

METHODS

We performed an online survey of undergraduate and graduate students at a mid-sized, private university that has 37 AEDs located throughout its two campuses.

RESULTS

267 students responded to the survey. Almost all respondents could identify CPR (98.5%) and an AED (88.4%) from images, but only 46.1% and 18.4%, respectively, could indicate the basic mechanism of CPR and AEDs. About a quarter (28.1%) of respondents were comfortable using an AED without assistance, compared with 65.5% when offered assistance. Of those who did not feel comfortable, 87.7% indicated that they were 'afraid of doing something wrong.' One out of 6 (17.6%) respondents knew that a student centre had an AED, and only 2% could recall its precise location within the building. Most (66.3%) respondents indicated they would look for an AED near fire extinguishers, followed by the entrance of a building (19.6%).

CONCLUSIONS

This study found that most students at an American university can identify CPR and AEDs, but do not understand their basic mechanisms of action or are willing to perform CPR or use AEDs unassisted. Recent CPR/AED training and 9-1-1 assistance increases comfort. The most common fear reported was incorrect CPR or AED use. Almost all students could not recall where an AED was located in a student centre.