The challenges and possibilities of public access defibrillation

Comparative Analysis of Out-of-Hospital Cardiac Arrest Outcomes in Health Clinics, Nursing Homes, and Public Places: Implications for Optimizing Automated External Defibrillator Strategies

Purpose

Various factors, such as event location and response time, influence the outcomes of out-of-hospital cardiac arrest (OHCA). Very few studies have explored the delivery of basic life support (BLS) to patients having OHCA at health clinics or nursing homes-settings with professional BLS providers. Thus, in this study, we compared prognostic and survival outcomes between health clinics, nursing homes, and other public places (eg, workplaces and sports facilities/recreational areas) to offer insights for optimizing OHCA outcomes.

Patients

This study included adults who had nontraumatic OHCA in Taoyuan City between January 2017 and December 2022.

Methods

We collected data on patient characteristics, emergency medical service parameters, onsite patient management, automated external defibrillator (AED) locations, OHCA prognosis, and survival outcomes. Multivariate analyses were performed to predict survival to discharge (primary outcome) and neurological outcomes at discharge (secondary outcome).

Results

During the study period, the numbers of OHCA events at health clinics, nursing homes, and other public places were 158, 208, and 1986, respectively. The mean age of OHCA in health medical clinics, nursing home and other public places were 63.4, 81.5 and 64.7, respectively (P value<0.001). The proportion of witnessed events, rate of bystander resuscitation, and frequency of AED utilization were the highest for health clinics (53.2% (84/158), 83.4% (132/158), and 13.3% (21/158), respectively, P value<0.001). The average AED-scene distances and response times were the lowest for health clinics (388.8 m and 5.4 min, respectively). In initial shockable rhythm group, the probabilities of survival to discharge at discharge were the highest for health clinics (aOR=1.41, 95% CI=1.04-1.81, P value=0.041)) and lowest for nursing homes (aOR=0.84, 95% CI=0.76-0.93, P value=0.024).

Conclusion

Our research shows that OHCA patients at medical health clinics have higher rates of witnessing and bystander CPR and AED usage than other public places. However, while survival rates for patients with shockable rhythms are slightly better at health clinics, the neurological outcomes are not significantly different. The AED-scene distances are too far to be used effectively.

The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.

Effects of Dispatcher-Assisted Public-Access Defibrillation Programs on the Outcomes of Out-of-Hospital Cardiac Arrest: A Before-and-After Study

BACKGROUND

Public access defibrillation (PAD) programs have been implemented globally over the past decade. Although PAD can substantially increase the survival of cardiac arrest, PAD use remains low. This study aimed to evaluate whether drawing upon the successful experiences of dispatcher-assisted cardiopulmonary resuscitation programs would increase the use of PAD in dispatcher-assisted PAD programs.

METHODS AND RESULTS

This study using a before-and-after design was conducted in Taoyuan City using a local out-of-hospital cardiac arrest registry system and data of dispatcher performance derived from audio recordings. The primary outcomes were the rate of bystander PAD use, sustained return of spontaneous circulation, survival to discharge, and favorable neurological outcomes. The secondary outcomes were the performance of dispatchers in terms of PAD instruction and dispatcher-assisted cardiopulmonary resuscitation administration, the time interval indicators of dispatcher-assisted cardiopulmonary resuscitation. A total of 1159 patients were included and divided into 2 groups: the before-run-in group (502 patients) and the after-run-in group (657 patients). No significant difference was observed between the 2 groups in terms of baseline characteristics. The rate of PAD use in the after-run-in group significantly increased from 5.0% to 8.7% (P=0.015). The rate of favorable neurological outcomes increased from 4.4% to 5.9%, which was not a statistically significant difference. Compared with the before-run-in group, the rate of successful automated external defibrillator acquisition was 13.5% in the after-run-in group (P<0.001).

CONCLUSIONS

Implementing a dispatcher-assisted PAD protocol in a municipality setting significantly increased bystander PAD use without affecting dispatcher performance in out-of-hospital cardiac arrest recognition, cardiopulmonary resuscitation instruction, or dispatcher-assisted cardiopulmonary resuscitation time indicators.

Drone delivery of automated external defibrillators compared with ambulance arrival in real-life suspected out-of-hospital cardiac arrests: a prospective observational study in Sweden

BACKGROUND

A novel approach to improve bystander defibrillation for out-of-hospital cardiac arrests is to dispatch and deliver an automated external defibrillator (AED) directly to the suspected cardiac arrest location by drone. The aim of this study was to investigate how often a drone could deliver an AED before ambulance arrival and to measure the median time benefit achieved by drone deliveries.

METHODS

In this prospective observational study, five AED-equipped drones were placed within two separate controlled airspaces in Sweden, covering approximately 200 000 inhabitants. Drones were dispatched in addition to standard emergency medical services for suspected out-of-hospital cardiac arrests and flight was autonomous. Alerts concerning children younger than 8 years, trauma, and emergency medical services-witnessed cases were not included. Exclusion criteria were air traffic control non-approval of flight, unfavourable weather conditions, no-delivery zones, and darkness. Data were collected from the dispatch centres, ambulance organisations, Swedish Registry for Cardiopulmonary Resuscitation, and the drone operator. Core outcomes were the percentage of cases for which an AED was delivered by a drone before ambulance arrival, and the median time difference (minutes and seconds) between AED delivery by drone and ambulance arrival. Explorative outcomes were percentage of attached drone-delivered AEDs before ambulance arrival and the percentage of cases defibrillated by a drone-delivered AED when it was used before ambulance arrival.

FINDINGS

During the study period (from April 21, 2021 to May 31, 2022), 211 suspected out-of-hospital cardiac arrest alerts occurred, and in 72 (34%) of those a drone was deployed. Among those, an AED was successfully delivered in 58 (81%) cases, and the major reason for non-delivery was cancellation by dispatch centre because the case was not an out-of-hospital cardiac arrest. In cases for which arrival times for both drone and ambulance were available (n=55), AED delivery by drone occurred before ambulance arrival in 37 cases (67%), with a median time benefit of 3 min and 14 s. Among these cases, 18 (49%) were true out-of-hospital cardiac arrests and a drone-delivered AED was attached in six cases (33%). Two (33%) had a shockable first rhythm and were defibrillated by a drone-delivered AED before ambulance arrival, with one person achieving 30-day survival. No adverse events occurred. AED delivery (not landing) was made within 15 m from the patient or building in 91% of the cases.

INTERPRETATION

AED-equipped drones dispatched in cases of suspected out-of-hospital cardiac arrests delivered AEDs before ambulance arrival in two thirds of cases, with a clinically relevant median time benefit of more than 3 min. This intervention could potentially decrease time to attachment of an AED, before ambulance arrival.

FUNDING

Swedish Heart Lung Foundation.

[Differences between Spain's autonomous communities in the availability of semi-automatic external defibrillators outside the healthcare setting]

BACKGROUND

Early defibrillation is one of the interventions that can most influence the prognosis of cardiac arrest. The objectives of this study were to determine the number of automatic external defibrillators outside the healthcare setting in each autonomous community in Spain and to compare the legislation of each autonomous community on the mandatory installation of defibrillators outside the healthcare setting.

METHODS

A cross-sectional observational study was carried out between December 2021 and January 2022 by consulting official data in the 17 Spanish autonomous communities.

RESULTS

Complete data on the number of registered defibrillators were obtained from 15 autonomous communities. The number of defibrillators ranged from 35 to 126 per 100,000 inhabitants. At the global level, differences were observed between communities with mandatory defibrillator installation and those without (92.1 vs. 57.8 defibrillators/100,000 inhabitants).

CONCLUSIONS

There is heterogeneity in the provision of defibrillators outside the health care setting, which seems to be related to the diversity of legislation on the mandatory installation of defibrillators.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Public access defibrillation: challenges and new solutions

PURPOSE OF REVIEW

The purpose of this article is to review the current status of public access defibrillation and the various utility modalities of early defibrillation.

RECENT FINDINGS

Defibrillation with on-site automated external defibrillators (AEDs) has been the conventional approach for public access defibrillation. This strategy is highly effective in cardiac arrests occurring in close proximity to on-site AEDs; however, only a few cardiac arrests will be covered by this strategy. During the last decades, additional strategies for public access defibrillation have developed, including volunteer responder programmes and drone assisted AED-delivery. These programs have increased chances of early defibrillation within a greater radius, which remains an important factor for survival after out-of-hospital cardiac arrest.

SUMMARY

Recent advances in the use of public access defibrillation show great potential for optimizing early defibrillation. With new technological solutions, AEDs can be transported to the cardiac arrest location reaching OHCAs in both public and private locations. Furthermore, new technological innovations could potentially identify and automatically alert the emergency medical services in nonwitnessed OHCA previously left untreated.

Association Between Number of Volunteer Responders and Interventions Before Ambulance Arrival for Cardiac Arrest

BACKGROUND

Volunteer responder (VR) programs for activation of laypersons in out-of-hospital cardiac arrest (OHCA) have been deployed worldwide, but the optimal number of VRs to dispatch is unknown.

OBJECTIVES

The purpose of this study was to investigate the association between the number of VRs arriving before Emergency Medical Services (EMS) and the proportion of bystander cardiopulmonary resuscitation (CPR) and defibrillation.

METHODS

We included OHCAs not witnessed by EMS with VR activation from the Capital Region (September 2, 2017, to May 14, 2019) and the Central Region of Denmark (November 5, 2018, to December 31, 2019). We created 4 groups according to the number of VRs arriving before EMS: 0, 1, 2, and 3 or more. Using a logistic regression model adjusted for EMS response time, we examined associations between the number of VRs arriving before EMS and bystander CPR and defibrillation.

RESULTS

We included 906 OHCAs. The adjusted ORs for bystander CPR were 2.40 (95% CI: 1.42-4.05), 3.18 (95% CI: 1.39-7.26), and 2.70 (95% CI: 1.32-5.52) when 1, 2, or 3 or more VRs arrived before EMS (reference), respectively. The adjusted OR for bystander defibrillation increased when 1 (1.97 [95% CI: 1.12-3.52]), 2 (2.88 [95% CI: 1.48-5.58]), or 3 or more (3.85 [95% CI: 2.11-7.01]) VRs arrived before EMS (reference). The adjusted OR of bystander defibrillation increased to 1.95 (95% CI: 1.18-3.22) when ≥3 VRs arrived first compared with 1 VR arriving first (reference).

CONCLUSIONS

We found an association of increased bystander CPR and defibrillation when 1 or more VRs arrived before the EMS with a trend toward increased bystander defibrillation with increasing number of VRs arriving first.

Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study

BACKGROUND

To evaluate whether a simplified self-instruction card can help potential rescue providers use automated external defibrillators (AEDs) more accurately and quickly.

METHODS

From June 1, 2018, to November 30, 2019, a prospective longitudinal randomized controlled simulation study was conducted among 165 laypeople (18-65 years old) without prior AED training. A self-instruction card was designed to illuminate key AED operation procedures. Subjects were randomly divided into the card (n=83) and control (n=82) groups with age stratification. They were then individually evaluated in the same simulated scenario to use AED with (card group) or without the self-instruction card (control group) at baseline, post-training, and at the 3-month follow-up.

RESULTS

At baseline, the card group reached a significantly higher proportion of successful defibrillation (31.1% vs. 15.9%, P=0.03), fully baring the chest (88.9% vs. 63.4%, P<0.001), correct electrode placement (32.5% vs. 17.1%, P=0.03), and resuming cardiopulmonary resuscitation (CPR) (72.3% vs. 9.8%, P<0.001). At post-training and follow-up, there were no significant differences in key behaviors, except for resuming CPR. Time to shock and time to resume CPR were shorter in the card group, while time to power-on AED was not different in each phase of tests. In the 55-65 years group, the card group achieved more skill improvements over the control group compared to the other age groups.

CONCLUSION

The self-instruction card could serve as a direction for first-time AED users and as a reminder for trained subjects. This could be a practical, cost-effective way to improve the AED skills of potential rescue providers among different age groups, including seniors.

The impact of alcohol use on the quality of cardiopulmonary resuscitation among festival attendees: A prespecified analysis of a randomised trial

BACKGROUND

Cardiac arrests often occur in public places, but despite the undisputed impact of bystander CPR, it is debated whether one should act as a rescuer after alcohol consumption due to the perceived adverse effects. We provide the first objective data on the impact of alcohol levels on CPR-skills.

METHODS

Pre-specified analysis of a randomised study at the Lowlands music festival (August 2019, the Netherlands) on virtual reality vs face-to-face CPR-training. Participants with an alcohol level ≥ 0.5‰ (WHO-endorsed cut-off for traffic participation) were eligible provided they successfully completed a tandem gait test. We studied alcohol levels (AL, ‰) in relation to CPR-quality (compression depth and rate) and CPR-scenario performance.

RESULTS

Median age of the 352 participants was 26 (22-31) years, 56% were female, with n = 214 in Group 1 (AL = 0‰), n = 85 in Group 2 (AL = 0-0.5‰) and n = 53 in Group 3 (AL ≥ 0.5‰). There were no significant differences in CPR-quality (depth: 57 [49-59] vs 57 [51-60] vs 55 mm [47-59], p = 0.16; rate: 115 [104-121] vs 114 [106-122] vs 111 min^-1 [95-120], p = 0.19). There were no significant correlations between alcohol level and compression depth (Spearman's rho -0.113, p = 0.19) or rate (Spearman's rho -0.073, p = 0.39). CPR-scenario performance scores (maximum 13) were not different between groups (12 (9-13) vs 12 (9-13) vs 11 (9-13), p = 0.80).

CONCLUSION

In this study on festival attendees, we found no association between alcohol levels and CPR-quality or scenario performance shortly after training.

TRIAL REGISTRATION

Lowlands Saves Lives is registered on https://www.

CLINICALTRIALS

gov (NCT04013633).

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France

AIM

To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France.

METHODS

This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others).

RESULTS

A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003).

CONCLUSIONS

Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Possibilities of Using UAVs in Pre-Hospital Security for Medical Emergencies

The term unmanned aerial vehicle (UAV) was post-applied in the 1980s to describe remotely piloted multi-purpose, unmanned, autonomous aircraft. The terms unmanned aircraft systems with data terminal connectivity (UAS) and remotely piloted aircraft systems (RPV, RPAS-military systems) are also used. This review aims to analyze the feasibility of using UAVs to support emergency medical systems in the supply and urgent care ranges. The implementation of drones in the medical security system requires proper planning of service cooperation, division of the area into sectors, assessment of potential risks and opportunities, and legal framework for the application. A systematic literature search was conducted to assess the applicability based on published scientific papers on possible medical drone applications in the field of urgent mode. The widespread applications of UAVs in healthcare are concerned with logistics, scope, and transportability, with framework legal constraints to effectively exploit opportunities for improving population health, particularly for costly critical situations.

Development of Low-Fidelity Virtual Replicas of Products for Usability Testing

Designers perform early-stage formative usability tests with low-fidelity prototypes to improve the design of new products. This low-tech prototype style reduces the manufacturing resources but limits the functions that can be assessed. Recent advances in technology enable designers to create low-fidelity 3D models for users to engage in a virtual environment. Three-dimensional models communicate design concepts and are not often used in formative usability testing. The proposed method discusses how to create a virtual replica of a product by assessing key human interaction steps and addresses the limitations of translating those steps into a virtual environment. In addition, the paper will provide a framework to evaluate the usability of a product in a virtual setting, with a specific emphasis on low-resource online testing in the user population. A study was performed to pilot the subject’s experience with the proposed approach and determine how the virtual online simulation impacted the performance. The study outcomes demonstrated that subjects were able to successfully interact with the virtual replica and found the simulation realistic. This method can be followed to perform formative usability tests earlier and incorporate subject feedback into future iterations of their design, which can improve safety and product efficacy.

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.

Effect of topography and weather on delivery of automatic electrical defibrillator by drone for out-of-hospital cardiac arrest

Delivery of automatic electrical defibrillator (AED) by unmanned aerial vehicle (UAV) was suggested for out-of-hospital cardiac arrest (OHCA). The goal of this study is to assess the effect of topographic and weather conditions on call to AED attach time by UAV-AED. We included OHCA patients from 2013 to 2016 in Seoul, South Korea. We developed a UAV-AED flight simulator using topographic information of Seoul for Euclidean and topographic flight pathway including vertical flight to overcome high-rise structures. We used 4 kinds of UAV flight scenarios according to weather conditions or visibility. Primary outcome was emergency medical service (EMS) call to AED attach time. Secondary outcome was pre-arrival rate of UAV-AED before current EMS based AED delivery. Call to AED attach time in topographic pathway was 7.0 min in flight and control advanced UAV and 8.0 min in basic UAV model. Pre-arrival rate in Euclidean pathway was 38.0% and 16.3% for flight and control advanced UAV and basic UAV. Pre-arrival rate in the topographic pathway was 27.0% and 11.7%, respectively. UAV-AED topographic flight took longer call to AED attach time than Euclidean pathway. Pre-arrival rate of flight and control advanced UAV was decreased in topographic flight pathway compared to Euclidean pathway.

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.

Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities

Over the past 25 years, naloxone has emerged as a critical lifesaving overdose antidote. Public health advocates and community activists established early methods for naloxone distribution to people who inject drugs, but a legacy of stigmatization and opposition to universal naloxone access continues to limit the drug's full potential to reduce opioid-related mortality. The establishment of naloxone distribution programs under the umbrella of syringe exchange programs faces the same practical, ideological and financial barriers to expansion similar to those faced by syringe exchange programs themselves. The expansion of naloxone from the confines of a few syringe exchange programs to what we see today represents an enormous triumph for the grass-roots activists, service providers, and public health professionals who have fought to guarantee lay access to naloxone. Despite the extensive efforts to expand access to naloxone, naloxone continues to remains a scarce resource in many US localities. Considerable naloxone "deserts" remain and even where there is naloxone access, it does not always reach those at risk. Promising areas for expansion include the development of more robust telehealth methods for naloxone distribution, including subsidized mail delivery programs; lowering barriers to pharmacy access; working with hospitals, ambulances, and law enforcement to expand naloxone "leave behind" programs; providing naloxone co-prescription with medications for opioid use disorder; and working with prisons, shelters, and networks of people who use drugs to increase access to the lifesaving medication. Efforts to ensure over-the-counter and low- or no-cost naloxone are ongoing and stand alongside medication-assisted treatments as efficacious, readily-actionable, and cost-efficient population-level interventions available for combatting opioid-related overdose in the United States.

How to improve automated external defibrillator placement for out-of-hospital cardiac arrests: A case study

Introduction

In out-of-hospital cardiac arrests (OHCAs), the use of an automatic external defibrillator (AED) by a bystander remains low, as AEDs may be misplaced with respect to the locations of OHCAs. As the distribution of historical OHCAs is potentially predictive of future OHCA locations, the purpose of this study is to assess AED positioning with regard to past locations of OHCAs, in order to improve the efficiency of public access defibrillation programs.

Methods

This is a retrospective observational study from 2014 to 2018. The locations of historical OHCAs and AEDs were loaded into a geodata processing tool. Median distances between AEDs were collected, as well as the number and rates of OHCAs covered (distance of <100 meters from the nearest AED). Areas with high densities of uncovered OHCAs (hotspots) were identified in order to propose the placement of additional AEDs. Areas over-covered by AEDs (overlays) were also identified in order to propose the relocation of overlapping AEDs.

Results

There were 2,971 OHCA, 79.3% of which occurred at home, and 633 AEDs included in the study. The global coverage rate was 7.5%. OHCAs occurring at home had a coverage rate of 4.5%. Forty hotspots were identified, requiring the same number of additional AEDs. The addition of these would increase the coverage from 7.5% to 17.6%. Regarding AED overlays, 17 AEDs were found to be relocatable without reducing the AED coverage of historical OHCAs.

Discussion

This study confirms that geodata tools can assess AED locations and increase the efficiency of their placement. Historical hotspots and AED overlays should be considered, with the aim of efficiently relocating or adding AEDs. At-home OHCAs should become a priority target for future public access defibrillation programs as they represent the majority of OHCAs but have the lowest AED coverage rates.

Improving bystander defibrillation in out-of-hospital cardiac arrests at home

Aims:

Most out-of-hospital cardiac arrests occur at home with dismal bystander defibrillation rates. We investigated automated external defibrillator coverage of home arrests, and the proportion potentially reachable with an automated external defibrillator before emergency medical service arrival according to different bystander activation strategies.

Methods and results:

Cardiac arrests in homes (private/nursing/senior homes) in Copenhagen, Denmark (2008–2016) and registered automated external defibrillators (2007–2016), were identified. Automated external defibrillator coverage (distance from arrest to automated external defibrillator) and accessibility at the time of arrest were examined according to route distance to nearest automated external defibrillator and emergency medical service response time. The proportion of arrests reachable with an automated external defibrillator by bystander was calculated using two-way (from patient to automated external defibrillator and back) and one-way (from automated external defibrillator to patient) potential activation strategies. Of 1879 home arrests, automated external defibrillator coverage ≤100 m was low (6.3%) and a two-way bystander could potentially only retrieve an accessible automated external defibrillator before emergency medical service in 31.1% (n=37) of cases. If a bystander only needed to travel one-way to bring an automated external defibrillator (≤100 m, ≤250 m and ≤500 m), 45.4% (n=54/119), 37.1% (n=196/529) and 29.8% (n=350/1174) could potentially be reached before the emergency medical service based on current automated external defibrillator accessibility.

Conclusions:

Few home arrests were reachable with an automated external defibrillator before emergency medical service if bystanders needed to travel from patient to automated external defibrillator and back. However, nearly one-third of arrests ≤500 m of an automated external defibrillator could be reached before emergency medical service arrival if the bystander only needed to travel one-way from the automated external defibrillator to the patient.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Integration of novel monitoring devices with machine learning technology for scalable cardiovascular management

Ambulatory monitoring is increasingly important for cardiovascular care but is often limited by the unpredictability of cardiovascular events, the intermittent nature of ambulatory monitors and the variable clinical significance of recorded data in patients. Technological advances in computing have led to the introduction of novel physiological biosignals that can increase the frequency at which abnormalities in cardiovascular parameters can be detected, making expert-level, automated diagnosis a reality. However, use of these biosignals for diagnosis also raises numerous concerns related to accuracy and actionability within clinical guidelines, in addition to medico-legal and ethical issues. Analytical methods such as machine learning can potentially increase the accuracy and improve the actionability of device-based diagnoses. Coupled with interoperability of data to widen access to all stakeholders, seamless connectivity (an internet of things) and maintenance of anonymity, this approach could ultimately facilitate near-real-time diagnosis and therapy. These tools are increasingly recognized by regulatory agencies and professional medical societies, but several technical and ethical issues remain. In this Review, we describe the current state of cardiovascular monitoring along the continuum from biosignal acquisition to the identification of novel biosensors and the development of analytical techniques and ultimately to regulatory and ethical issues. Furthermore, we outline new paradigms for cardiovascular monitoring.

Advances in cardiovascular monitoring technologies have resulted in an influx of consumer-targeted wearable sensors that have the potential to detect numerous heart conditions. In this Review, Krittanawong and colleagues describe processes involved in biosignal acquisition and analysis of cardiovascular monitors, as well as their associated ethical, regulatory and legal challenges.

Advances in the use of cardiovascular monitoring technologies, such as the development of novel portable sensors and machine learning algorithms that can provide near-real-time diagnosis, have the potential to provide personalized care.

Wearable sensor technologies can detect numerous biosignals, such as cardiac output, blood-pressure levels and heart rhythm, and can integrate multiple modalities.

The use of novel biosignals for diagnosis raises concerns regarding accuracy and actionability within clinical guidelines, in addition to medical, legal and ethical issues.

Machine learning-based interpretation of biosensor data can facilitate rapid evaluation of the haemodynamic consequences of heart failure or arrhythmias, but is limited by the presence of noise and training data that might not be representative of the real-world clinical setting.

The use of data derived from cardiovascular monitoring devices is associated with numerous challenges, such as data security, accessibility and ownership, in addition to other ethical and regulatory concerns.

Utility of Abnormal Head Computed Tomography in Predicting Outcome in Out-of-Hospital Cardiac Arrest Victims

Head computed tomography (HCT) is often performed postcardiac arrest to assess for hypoxic-ischemic brain injury. Our primary objective was to assess whether cerebral edema (CE) on early HCT is associated with poor survival and neurologic outcome after out-of-hospital cardiac arrest (OHCA).We included subjects from a prospectively collected database of OHCA adults who received targeted temperature management at two hospitals from July 2009 to July 2018. We included cases if an emergency department (ED) HCT was performed. Patient demographics and cardiac arrest variables were collected. HCT results were abstracted from radiology reports. HCT findings were categorized as no acute disease, evidence of CE, or excluded (bleed, tumor, and stroke). Outcomes were survival to discharge or dichotomized discharge cerebral performance category (CPC) of 1-2 (good neurologic outcome) versus 3-5 (poor neurologic outcome). Univariate and multivariate analyses were performed. There were 425 OHCA, of which 315 had ED HCT with 277 cases included. Patients were predominately male (65.0%), average age of 60.9 years and average body mass index of 30.5. Of all cases, 44 (15.9%) showed CE on computed tomography. Univariate analysis demonstrated that CE was associated with 9.2-fold greater odds of poor outcome (odds ratio [OR]: 9.23; 95% confidence interval [CI] 1.73-49.2) and 9.1-fold greater odds of death (OR: 9.09, 95% CI 2.4-33.9). In adjusted analysis, CE was associated with a poor CPC outcome (adjusted odds ratios [AOR]: 14.9, 95% CI 2.49-88.4), and death (AOR: 13.7, 95% CI 3.26-57.4). Adjusted survival analysis demonstrated that patients with CE on HCT had 3.6-fold greater hazard of death than those without CE (hazard ratios 3.56, 95% CI 2.34-5.41). The results identify that CE on HCTs early in the postarrest period in OHCA patients is strongly associated with poor rates of survival and neurologic outcome. Prospective work is needed to further define the role of early HCT in postarrest neuroprognostication.

Development of a Novel Framework to Propose New Strategies for Automated External Defibrillators Deployment Targeting Residential Out-Of-Hospital Cardiac Arrests: Application to the City of Milan

Public Access Defibrillation (PAD) is the leading strategy in reducing time to first defibrillation in cases of Out-Of-Hospital Cardiac Arrest (OHCA), but PAD programs are underperforming considering their potentiality. Our aim was to develop an analysis and optimization framework, exploiting georeferenced information processed with Geographic Information Systems (GISs), specifically targeting residential OHCAs. The framework, based on an historical database of OHCAs, location of Automated External Defibrillators (AEDs), topographic and demographic information, proposes new strategies for AED deployment focusing on residential OHCAs, where performance assessment was evaluated using AEDs “catchment area” (area that can be reached within 6 min walk along streets). The proposed framework was applied to the city of Milan, Lombardy (Italy), considering the OHCA database of four years (2015–2018), including 8152 OHCA, of which 7179 (88.06%) occurred in residential locations. The proposed strategy for AEDs deployment resulted more effective compared to the existing distribution, with a significant improvement (from 41.77% to 73.33%) in OHCAs’ spatial coverage. Further improvements were simulated with different cost scenarios, resulting in more cost-efficient solutions. Results suggest that PAD programs, either in brand-new territories or in further improvements, could significantly benefit from a comprehensive planning, based on mathematical models for risk mapping and on geographical tools.

The automated external defibrillator, an underused simple life-saving device: a review of the literature. A joint document from the Italian Resuscitation Council (IRC) and Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC)

: The role of early defibrillation has been well established as a pivotal ring of the chain of survival since the nineties. In the following years, the scientific evidences about the beneficial role of early defibrillation have grown, and most of all, it has been demonstrated that the main determinant of survival is the time of defibrillation more than the type of rescuer. Early lay defibrillation was shown to be more effective than delayed defibrillation by healthcare providers. Moreover, because of the ease of use of automated external defibrillators (AEDs), it has been shown that also untrained lay rescuers can safely use an AED leading the guidelines to encourage early defibrillation by untrained lay bystanders. Although strong evidence has demonstrated that an increase in AED use leads to an increase in out-of-hospital cardiac arrest (OHCA) survival, the rate of defibrillation by laypeople is quite variable worldwide and very low in some realities. Our review of the literature about lay defibrillation highlights that the AED is a life-saving device as simple and well tolerated as underused.

Global positioning system alerted volunteer first responders arrive before emergency medical services in more than four out of five emergency calls

AIM

To evaluate response rates for volunteer first responders (VFRs) activated by use of a smartphone GPS-tracking system and to compare response times of VFRs with those of emergency medical services (EMS). Furthermore, to evaluate 30-day-survival after out-of-hospital cardiac arrest (OHCA) on a rural island.

METHODS

Since 2012 a GPS-tracking system has been used on a rural island to activate VFRs during all emergency calls requesting an EMS. When activated, three VFRs were recruited and given distinct roles, including collection of the nearest automatic external defibrillator (AED). We retrospectively investigated EMS response data from April 2012 to December 2017. These were matched with VFR response times from the GPS-tracking system. The 30-day survival in OHCA patients was also assessed.

RESULTS

In 2266 of 2662 emergency calls (85%) at least one VFR arrived to the site before EMS. Median response times for VFRs (n = 2662) was 4:46 min:sec (IQR 3:16-6:52) compared with 10:13 min:sec (6:14-13:41) for EMS (p < 0.0001). A total of 17 OHCAs took place in public locations and 65 in residential areas. Thirty-day survival in these were 24% and 15%, respectively.

CONCLUSION

Use of a smartphone GPS-tracking system to dispatch VFRs ensures that in more than four of five cases, a VFR arrives to the site before EMS. Response times for VFRs were also found to be lower than EMS response times. Finally, the 30-day survival of OHCA patients in a rural area, based on these results, surpass our expectations.

First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe

Background

In Europe, survival rates after out-of-hospital cardiac arrest (OHCA) vary widely. Presence/absence and differences in implementation of systems dispatching First Responders (FR) in order to arrive before Emergency Medical Services (EMS) may contribute to this variation. A comprehensive overview of the different types of FR-systems used across Europe is lacking.

Methods

A mixed-method survey and information retrieved from national resuscitation councils and national EMS services were used as a basis for an inventory. The survey was sent to 51 OHCA experts across 29 European countries.

Results

Forty-seven (92%) OHCA experts from 29 countries responded to the survey. More than half of European countries had at least one region with a FR-system. Four categories of FR types were identified: (1) firefighters (professional/voluntary); (2) police officers; (3) citizen-responders; (4) others including off-duty EMS personnel (nurses, medical doctors), taxi drivers. Three main roles for FRs were identified: (a) complementary to EMS; (b) part of EMS; (c) instead of EMS. A wide variation in FR-systems was observed, both between and within countries.

Conclusions

Policies relating to FRs are commonly implemented on a regional level, leading to a wide variation in FR-systems between and within countries. Future research should focus on identifying the FR-systems that most strongly influence survival. The large variation in local circumstances across regions suggests that it is unlikely that there will be a ‘one-size fits all’ FR-system for Europe, but examining the role of FRs in the Chain of Survival is likely to become an increasingly important aspect of OHCA research.

A local neighborhood volunteer network improves response times for simulated cardiac arrest

AIM

Each minute is crucial in the treatment of out-of-hospital cardiac arrest (CA). Immediate chest compressions and early defibrillation are keys to good outcomes. We hypothesized that a coordinated effort of alerting trained local neighborhood volunteers (vols) simultaneously with 911 activation of professional EMS providers would result in substantial decreases in call-to-arrival times, leading to earlier CPR and defibrillation.

METHODS

We developed a program of simultaneously alerting CPR- and AED-trained neighborhood vols and the local EMS system for CA events in a retirement residential neighborhood in Southern Arizona, encompassing approximately 440 homes. The closest EMS station is 3.3 miles from this neighborhood. Within this neighborhood, 15 vols and the closest EMS station were involved in multiple days of mock CA notifications and responses.

RESULTS

The two groups differed significantly in distance to the mock CA event and in response times. The volunteers averaged 0.3 ± 0.2 miles from the mock CA incidences while the closest EMS station averaged 3.4 ± 0.1 miles away (p < 0.0001). Response times (time from call to arrival) also differed. Two volunteers, one bringing an AED, averaged 1 min 38 s ± 53 s in Phase 1, while it took the EMS service an average of 7 min 20 s ± 1 min 13 s to arrive on scene; p < 0.0001.

CONCLUSION

Local neighborhood volunteers were geographically closer and arrived significantly sooner at the mock CA scene than did the EMS service. The approximate time savings from call to arrival with the volunteers was 4-6 min.

Evaluating health facility access using Bayesian spatial models and location analysis methods

BACKGROUND

Floating catchment methods have recently been applied to identify priority regions for Automated External Defibrillator (AED) deployment, to aid in improving Out of Hospital Cardiac Arrest (OHCA) survival. This approach models access as a supply-to-demand ratio for each area, targeting areas with high demand and low supply for AED placement. These methods incorporate spatial covariates on OHCA occurrence, but do not provide precise AED locations, which are critical to the initial intent of such location analysis research. Exact AED locations can be determined using optimisation methods, but they do not incorporate known spatial risk factors for OHCA, such as income and demographics. Combining these two approaches would evaluate AED placement impact, describe drivers of OHCA occurrence, and identify areas that may not be appropriately covered by AED placement strategies. There are two aims in this paper. First, to develop geospatial models of OHCA that account for and display uncertainty. Second, to evaluate the AED placement methods using geospatial models of accessibility. We first identify communities with the greatest gap between demand and supply for allocating AEDs. We then use this information to evaluate models for precise AED location deployment.

METHODS

Case study data set consisted of 2802 OHCA events and 719 AEDs. Spatial OHCA occurrence was described using a geospatial model, with possible spatial correlation accommodated by introducing a conditional autoregressive (CAR) prior on the municipality-level spatial random effect. This model was fit with Integrated Nested Laplacian Approximation (INLA), using covariates for population density, proportion male, proportion over 65 years, financial strength, and the proportion of land used for transport, commercial, buildings, recreation, and urban areas. Optimisation methods for AED locations were applied to find the top 100 AED placement locations. AED access was calculated for current access and 100 AED placements. Priority rankings were then given for each area based on their access score and predicted number of OHCA events.

RESULTS

Of the 2802 OHCA events, 64.28% occurred in rural areas, and 35.72% in urban areas. Additionally, over 70% of individuals were aged over 65. Supply of AEDs was less than demand in most areas. Priority regions for AED placement were identified, and access scores were evaluated for AED placement methodology by ranking the access scores and the predicted OHCA count. AED placement methodology placed AEDs in areas with the highest priority, but placed more AEDs in areas with more predicted OHCA events in each grid cell.

CONCLUSION

The methods in this paper incorporate OHCA spatial risk factors and OHCA coverage to identify spatial regions most in need of resources. These methods can be used to help understand how AED allocation methods affect OHCA accessibility, which is of significant practical value for communities when deciding AED placements.

Public access of automated external defibrillators in a metropolitan city of China

BACKGROUND

Public access of automated external defibrillator (AED) is an important public health strategy for improving survival of cardiac arrest. Major metropolitan cities in China are increasingly investing and implementing public access defibrillator programs, but the effectiveness of these programs remains unclear. This study aims to evaluate the public accessibility of AED in Shanghai, a major metropolitan city in China.

METHODS

From July 1 to September 30, 2018, all AED locations indicated by AED Access Map Apps were visited and investigated in three most densely distributing areas of AED (Huangpu District, Xuhui District, and Central Area of the Pudong New District) in Shanghai. Two AED Access Map APPs were used to identify the location of AEDs. Characteristics of and the barriers to access, the AED sites were recorded. Awareness and skills of first aid and AED among on-site staff of the AED installation sites were evaluated.

RESULTS

A total of 283 sites were marked on two AED Apps. One hundred and seventy (60%) locations were accessible, and 142 (50%) were actually with AEDs installed. Among those AED installed sites, 112 (79%) were completely identifiable to the information on the maps, 20 (14%) were inconsistent and 10 (7%) were inaccurate on the maps. Ninety-four (66%) AEDs had visible signs and information around the location, 7 (5%) AEDs had signs outside of the location, and 107 (75%) sites had educational instructions. In addition, 230 individuals who were around the AED site were interviewed. Among them, 79 (34%) had good knowledge of AED. After shown the picture of AED, 112 (49%) knew whether there was AED in the site, and 108 (47%) knew the AED's location. Eighty-seven (38%) staff have received first aid training, and among them 26 (30%) reported that they had skills in operating the AED.

CONCLUSIONS

Public placement and accessibility of AEDs, related public signs and information on AED, and staff's awareness about AED were not optimal in Shanghai. Continuing efforts should be made to improve public accessibility and public awareness, knowledge, and user skills of AED.

Cost-effectiveness of public automated external defibrillators

BACKGROUND

Despite a consistent association with improved outcomes, public automated external defibrillators (AEDs) are rarely used in out-of-hospital cardiac arrest. One of the barriers towards increased use might be cost-effectiveness.

METHODS

We compared the cost-effectiveness of public AEDs to no AEDs for out-of-hospital cardiac arrest in the United States over a life-time horizon. The analysis assumed a societal perspective and results are presented as costs per quality-adjusted life year (QALY). Model inputs were based on reviews of the literature. For the base case, we modelled an annual cardiac arrest incidence per AED of 20%. A probabilistic sensitivity analysis was conducted to account for joint parameter uncertainty.

RESULTS

The no AED strategy resulted in 1.63 QALYs at a cost of $28,964. The AED strategy yielded an additional 0.26 QALYs for an incremental increase in cost of $13,793 per individual. The AED strategy yielded an incremental cost-effectiveness ratio of $53,797 per QALY gained. The yearly incidence of cardiac arrests occurring in the presence of an AED had minimal effect on the incremental cost-effectiveness ratio except at very low incidences. In several sensitivity analyses across a plausible range of health care and societal estimates, the AED strategy remained cost-effective. In the probabilistic sensitivity analysis, the AED strategy was cost-effective in 43%, 85%, and 91% of the scenarios at a willingness-to-pay threshold of $50,000, $100,000, and $150,000 per QALY gained, respectively.

CONCLUSION

Public AEDs are a cost-effective public health intervention in the United States. These findings support widespread dissemination of public AEDs.

New Concepts in Sudden Cardiac Arrest to Address an Intractable Epidemic: JACC State-of-the-Art Review

Sudden cardiac arrest (SCA) is one of the largest causes of mortality globally, with an out-of-hospital survival below 10% despite intense research. This document outlines challenges in addressing the epidemic of SCA, along the framework of respond, understand and predict, and prevent. Response could be improved by technology-assisted orchestration of community responder systems, access to automated external defibrillators, and innovations to match resuscitation resources to victims in place and time. Efforts to understand and predict SCA may be enhanced by refining taxonomy along phenotypical and pathophysiological "axes of risk," extending beyond cardiovascular pathology to identify less heterogeneous cohorts, facilitated by open-data platforms and analytics including machine learning to integrate discoveries across disciplines. Prevention of SCA must integrate these concepts, recognizing that all members of society are stakeholders. Ultimately, solutions to the public health challenge of SCA will require greater awareness, societal debate and focused public policy.

Commentary on Madah-Amiri et al. (2019): Beyond saturation

Improving upon current uptake rates resulting from naloxone saturation efforts requires that we look beyond existing delivery mechanisms toward novel distribution agents and venues with the greatest potential to reduce overdose (OD) morbidity and mortality.

Automated External Defibrillator Geolocalization with a Mobile Application, Verbal Assistance or No Assistance: A Pilot Randomized Simulation (AED G-MAP)

OBJECTIVE

Shockable rythms are common among victims of witnessed public out-of-hospital cardiac arrest (OHCA), but bystander defibrillation with a public automated external defibrillator (PAED) is rare. Instructions from the emergency medical dispatcher and mobile applications were developed to expedite the localization of PAEDs, but their effectiveness has not been compared.

METHODS

Participants were enrolled in a three-armed randomized simulation where they witnessed a simulated OHCA on a university campus, were instructed to locate a PAED and provide defibrillation. Participants were stratified and randomized to: (1) no assistance in finding the PAED, (2) assistance from a geolocalization mobile application (AED-Quebec), or (3) verbal assistance. Data collectors tracked each participant's time elapsed and distance traveled to shock.

RESULTS

Of the 52 volunteers participating in the study (46% male, mean age 37), 17 were randomized to the no assistance group, 18 to the mobile application group and 17 to the verbal group. Median (IQR) time to shock was, respectively, 10:00 min (7:49-10:00), 9:44 (6:30-10:00), and 5:23 (4:11-9:08), with statistically significant differences between the verbal group and the other groups (p ≤ 0.01). The success rate for defibrillation in <10 minutes was 35%, 56% and 76%. Multivariate regression of all participants pooled showed that knowledge of campus geography was the strongest predictor of shock in <10 minutes (aOR =14.3, 95% CI 1.85-99.9). Among participants without prior geographical knowledge, verbal assistance provided a trend towards decreased time to shock, but the differences over no assistance (7:28 vs. 10:00, p = 0.10) and over the mobile app (7:28 vs. 10:00, p = 0.11) were not statistically significant.

CONCLUSION

In a simulated environment, verbally providing OHCA bystanders with the nearest PAED's location appeared to be effective in reducing the time to defibrillation in comparison to no assistance and to an AED geolocalizing mobile app, but further research is required to confirm this hypothesis, ascertain the external validity of these results, and evaluate the real-life implications of these strategies.