Automated external defibrillators in health/fitness facilities: supplement to the AHA/ACSM Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities

Incidence, bystander emergency response management and outcomes of out-of-hospital cardiac arrest at exercise and sport facilities in Australia

OBJECTIVE

Despite growing emphasis on automated external defibrillators (AEDs) at sport venues in Australia, the risk of cardiac events at such locations is unknown. The aim of the present study was to investigate the incidence of out-of-hospital cardiac arrest (OHCA) at exercise and sport facilities (ESF) in Australia and the impact of effective bystander-initiated CPR and AED use on return of spontaneous circulation (ROSC) to hospital admission.

METHODS

Data were obtained from the Queensland Ambulance Service for the 8-year period between January 2007 and January 2015. Data were analysed using descriptive statistics, non-parametric correlational tests and logistic regression. The OHCA incidence rate (IR) for ESF categories was standardised for 100 000 participant-years.

RESULTS

Over the 8-year period, there were 250 OHCA events with a median age of 62 years (interquartile range 49-69) comprising mostly males (86.6%, n = 187). The risk of OHCA for 100 000 participants per year was highest at outdoor sports facilities (IR 5.1) followed by indoor sports or fitness facilities (IR 0.8). On arrival of paramedics, bystander-initiated CPR and AED was present at 12.4% (n = 31) of the cases achieving 33.3% (n = 9) ROSC to hospital admission. The odds of ROSC for effective CPR was 2.3 times the odds of ROSC for no CPR (P = 0.01).

CONCLUSION

These findings have implications for policy development by government agencies and major sport and exercise organisations to improve bystander CPR and AED. This can help to ensure that ESF can properly respond to cardiac emergencies to save lives.

Building community resilience: A scalable model for hemorrhage-control training at a mass gathering site, using the RE-AIM framework

BACKGROUND

In a decade, the US military reduced deaths from uncontrolled bleeding on the battlefield by 67%. This success, coupled with an increased incidence of mass shootings in the US, has led to multiple initiatives intent on translating hemorrhage-control readiness to the civilian sector. However, the best method to achieve widespread population-level hemorrhage-control readiness for civilians has not yet been elucidated. This study evaluates the implementation of American College of Surgeons Bleeding Control training at a National Football League stadium as a prospective model for general mass gathering site implementation.

METHODS

The American College of Surgeons' Bleeding Control Basic layperson hemorrhage-control training was implemented at Gillette Stadium in Massachusetts. The five domains are as follows: reach (demographics of study participants), effectiveness (correct tourniquet application after intervention), adoption (investigator, leadership, and participant efforts for sustainability of intervention), implementation (course details), and maintenance (correct tourniquet application at retention testing at 3 to 9 months).

RESULTS

A total of 562 employees were included in the study. Of those included employees, 58.7% reported having taken first-aid training and 17.3% reported having taken hemorrhage-control training. There was an increased mean likelihood to help (4.39 vs 4.09, P < .01) and comfort level to control hemorrhage (4.26 vs 3.60, P < .01) after training compared with before training, on a Likert scale (1-5). The stadium operations team located hemorrhage control kits with automatic external defibrillators, integrated layperson immediate-response awareness into its Web site, and developed a public safety announcement. The training, performed by physicians, nurses, and emergency medical technicians, consisted of a 30-minute lecture and a 30-minute hands-on skills-training course, with a class size of 24. The total number of sessions was 24.

CONCLUSION

Achieving initial hemorrhage-control readiness and maintenance at a mass gathering site through American College of Surgeons Bleeding Control training is feasible but requires significant commitment from training staff, site leadership, and financial resources.

Muscle fatigue in participants of indoor cycling

BACKGROUND

Indoor Cycling (IC) has been gaining recognition and popularity within recent years and few studies have investigated its benefits for sedentary participants.

OBJECTIVE

The aim of this study was to evaluate differences in the surface electromyography (sEMG) variables, heart rate (HR), and subjective effort in sedentary participants while they performed an IC session and to compare their results with the trained subjects, to answer the question: Are trained cyclists less susceptible to muscle fatigue, since it is expected that they make less effort?

DESIGN

Twenty-six volunteers were split into two groups according to their fitness status and weekly training load. Each participant completed an IC session in a private gym, lasting 45 minutes and were encouraged to follow the pedaling frequency and cycle resistance, within their limitations. Main Outcome Measures: HR, participants' subjective effort on the Borg Scale of Perceived Exertion (Borg Scale) and sEMG data were compared between groups.

RESULTS

28.6% of the sedentary participants withdrew from the study. Exercise intensity, assessed using the HR, was similar in both groups. The subjective perceived effort, assessed using the Borg Scale, was significantly higher in the sedentary group. All muscles considered in the sedentary group had higher variation levels of Root Mean Square (RMS) and Median Frequency (MF) than those in the trained group.

CONCLUSION

Sedentary participants are more likely to present fatigue and IC can be incorporated into protocols for this population, but their fitness levels should be taken into account because each performance depends on the individual's physical fitness.

LEVEL OF EVIDENCE

IIIb.

Cardiac emergency preparedness in health/fitness facilities in Australia

BACKGROUND

Health/fitness facilities are popular venues for physical activity, where increasingly more individuals at risk of cardiovascular events exercise to achieve positive health outcomes. The aim of our study was to analyze cardiac emergency preparedness in health/fitness facilities in Queensland, Australia.

DESIGN

Cross-sectional survey of health/fitness facilities in Queensland.

METHODS

A risk management questionnaire was administered over 7 months, July 2009 to January 2010, using an online or paper-based version. The data are presented as the proportion of survey respondents giving specific responses to questionnaire items related to cardiac emergency preparedness, especially the provision of automated external defibrillators (AEDs).

RESULTS

Fifty-two health/fitness facility managers responded to the survey. Most of the surveyed facilities conducted pre-activity screening (92%). Of those with a written emergency plan (79%), only 37% physically rehearsed their emergency response systems at regular intervals. Ninety-five percent of the facilities had fitness employees with a current first aid/cardiopulmonary resuscitation certificate and training. Of the 10 (19%) facilities with an on-site AED, only 6 had staff qualified to use the AED in an emergency, and only 6 had the AED as part of a public access defibrillator program.

CONCLUSION

This is the first study to report that cardiac emergency preparedness is not optimal in the health/fitness facilities in Australia. Development of policies and procedures for training health/fitness professionals in emergency procedures is needed to minimize the risk when exercise-induced cardiac events occur at health/fitness facilities.

Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations

This systematic review examines critically "best practices" in the training of qualified exercise professionals. Particular attention is given to the core competencies and educational requirements needed for working with clinical populations. Relevant information was obtained by a systematic search of 6 electronic databases, cross-referencing, and through the authors' knowledge of the area. The level and grade of the available evidence was established. A total of 52 articles relating to best practices and (or) core competencies in clinical exercise physiology met our eligibility criteria. Overall, current literature supports the need for qualified exercise professionals to possess advanced certification and education in the exercise sciences, particularly when dealing with "at-risk" populations. Current literature also substantiates the safety and effectiveness of exercise physiologist supervised stress testing and training in clinical populations.

The knowledge of public access to defibrillation in selected cities in Poland

INTRODUCTION

The Public Access to Defibrillation (PAD) program was designed to raise the awareness of sudden cardiac death (SCA) pre-hospital management among the community. The goal of the following research was to confirm the final impact of the Polish PAD program on various resident groups that differ by age, training and education level.

MATERIAL AND METHODS

The trial total number of participants reached 404 people from three cities divided into two groups. In group one (n = 295) were randomly selected people inside the trial area and in group two (n = 109) we had individuals who were theoretically trained in basic life support (BLS) algorithms, including the use of an automatic external defibrillator (AED). The research method was based on two different questionnaires completed by participants from each group.

RESULTS

The greatest knowledge of SCA, as well as the use of AED, and the best practical skills, were possessed by the residents of cities with a population over 100 000, aged between 18 and 30 years, who completed secondary or higher education (31.7%). The group with the smallest knowledge about SCA lived in the country (10.7%). The second group with little knowledge of the subject consisted mostly of individuals with primary education (4.19%) or professional abilities and over 50 years old (2.16%).

CONCLUSIONS

There must be some actions taken in order to increase the community awareness concerning automatic defibrillation. Training on AED and the possibility of practical exercise needs to be organized and should be conducted especially among residents of the countryside and people under 30 or over 50 years old.

Automated external defibrillators in health and fitness facilities

BACKGROUND

Exercise is encouraged to promote health, but it can be a trigger for sudden cardiac arrest (SCA) in individuals with underlying cardiovascular disease. In 2002, the American Heart Association and the American College of Sports Medicine issued recommendations for the presence of automated external defibrillators (AEDs) in health and fitness facilities.

OBJECTIVE

To assess emergency response planning for SCA and review the prevalence and past utilization of AEDs in health and fitness facilities in King County, WA.

METHODS

A cross-sectional survey was conducted in 2008 of health and fitness facilities (N = 136) in King County, WA, assessing the 2002 American Heart Association guidelines on AEDs and emergency response planning for SCA.

RESULTS

Sixty-three (46%) of 136 facilities completed the survey. Thirty-five percent of the total facilities had < 500 members, 21% had 500 to 1500 members, 16% had 1501 to 2500 members, and 29% had > 2500 members. Sixty-eight percent had an established emergency response plan for SCA. Only 40% of facilities had ≥ 1 AED on site (mean, 1.7; range, 0-6). Fitness centers with > 1500 members (71%) were more likely to have an AED on site compared with those with < 1500 members (14%) (P < 0.0001). Of the staff trained in cardiopulmonary resuscitation, 83% were fitness instructors, 73% were administrators, and 58% were front desk personnel. Four facilities reported an incident of SCA within the 12 months prior to completing the survey, which was a 6.4% incidence of SCA in responding facilities. All SCA cases occurred in facilities with > 1500 members. Only 2 of the 4 facilities with an SCA had an on-site AED. The individuals who had SCA were all men aged 50 to 65 years, with 2 men successfully resuscitated at the facility.

CONCLUSION

There is a substantial gap in guideline implementation between national recommendations and current emergency response planning for SCA in health and fitness facilities. Health and fitness facilities are strategic locations to place AEDs in an effort to improve outcomes from exercise-related SCA. Facilities with general memberships of > 1500 are encouraged to have on-site AEDs, given the high incidence of SCA.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

OBJECTIVE

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

BACKGROUND

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

RECOMMENDATIONS

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Cardiovascular issues in boxing and contact sports

Despite the inherent risks associated with exercise in general and boxing in particular, the sport has had a limited number of catastrophic cardiovascular events. Screening should be based on risks involved and become more extensive with the advancement of the athlete. Anatomic and electrophysiologic risks need to be assessed and may preclude participation with resultant life style and economic complications. There should be adequate preparation for the rare potential cardiovascular complication at all events, with the ability to rapidly assess and treat arrhythmias.

Location of Cardiac Arrests in the Public Access Defibrillation Trial

BACKGROUND

The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone.

OBJECTIVES

To describe the types of facilities that participated in the trial and to report the incidence of CA and survival in these different types of facilities.

METHODS

In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities and the numbers of presumed CAs, treatable CAs, and survivors are reported for each category of facilities.

RESULTS

There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) and golf courses (4.8) and lowest in office complexes (0.7) and hotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), and fitness centers (0.4) and lowest in office complexes (0.1) and residential facilities (0.0).

CONCLUSIONS

During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers and golf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, and fitness centers.

The Clinical Significance of Aerobic Exercise Testing and Prescription: From Apparently Healthy to Confirmed Cardiovascular Disease

Aerobic exercise testing clearly provides valuable clinical information in apparently healthy adults as well as a number of patient populations. Maximal aerobic capacity, either estimated from workload or measured directly, is perhaps the most frequently analyzed variable ascertained from such testing. This practice is warranted given the consistent prognostic significance of maximal aerobic capacity. Other variables obtained from the aerobic exercise test, such as the heart rate response during exercise and into recovery, the systolic and diastolic blood pressure responses during exercise, oxygen consumption at anaerobic threshold, and the ventilatory response to exercise, also provide important insight into an individual's health and prognosis. Furthermore, the aerobic exercise test is highly valuable in developing an individualized and safe exercise prescription. Aerobic exercise training goals, with respect to frequency, duration, frequency, and mode of exercise, are well established for the apparently healthy population as well as individuals at risk for or diagnosed with cardiovascular disease. Adherence to these physical activity recommendations clearly provides numerous health benefits, perhaps most important of which is a significant decrease in the risk for cardiovascular events and mortality. This review addresses concepts of aerobic exercise testing and training and discusses their clinical implications.

Automated external defibrillators in the Australian fitness industry

Sudden cardiac arrest (SCA) occurs in many thousands of Australians each year. Scientific evidence shows an increased survival rate for individuals who receive electrical defibrillation in the first few minutes after SCA. In the last decade automated (rhythm-detecting) external defibrillators (AEDs) have become available that are portable and affordable. Although still relatively rare, there is still the potential that SCA may occur when a person undertakes physical activity. Consequently, health/fitness centres are increasingly recognised as higher risk sites that may benefit from placement of AEDs. There are no laws in Australia requiring health/fitness centres to install AEDs. However, several international and professional organisations have "strongly encouraged" larger centres to install AEDs. Guidelines and algorithms are presented to help estimate the risk of SCA in fitness centres. Fitness centre placement is particularly important if the clientele is older or has a 'high-risk' profile, for example, clients with cardiovascular, respiratory or metabolic disease. International negligence case law and duty of care principles suggests the standard of care required in health/fitness centres may be increasing. Therefore, it may be prudent to install AEDs in larger centres and those in which higher risk groups are physically active.

Cardiovascular Emergency Preparedness in Recreation Facilities at Major US Universities: College Fitness Center Emergency Readiness

Recent American Heart Association/American College of Sports Medicine (AHA/ACSM) guidelines advocate preparticipation screening, planning, and rehearsal for emergencies and automated external defibrillators in all health/fitness facilities. The authors evaluated adherence to these recommendations at 158 recreational service departments in major US universities (51% response rate for 313 institutions queried). Many made their facilities available to unaffiliated residents, with 39% offering programs for those with special medical conditions. Only 18% performed universal preparticipation screening. Twenty-seven percent reported having 1 or more exercise-related instances of cardiac arrest or sudden cardiac death within the past 5 years. Seventy-three percent had an automated external defibrillator, but only 6% reported using it in an emergency. Almost all had written emergency plans, but only 50% posted their plans, and only 27% performed the recommended quarterly emergency drills. The authors' findings suggest low awareness of and adherence to the AHA/ACSM recommendations for identifying individuals at risk for exercise-related cardiovascular complications and for handling such emergencies in university-based fitness facilities. (

Exercise and Acute Cardiovascular Events

Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons. This scientific statement discusses the potential cardiovascular complications of exercise, their pathological substrate, and their incidence and suggests strategies to reduce these complications. Exercise-associated acute cardiac events generally occur in individuals with structural cardiac disease. Hereditary or congenital cardiovascular abnormalities are predominantly responsible for cardiac events among young individuals, whereas atherosclerotic disease is primarily responsible for these events in adults. The absolute rate of exercise-related sudden cardiac death varies with the prevalence of disease in the study population. The incidence of both acute myocardial infarction and sudden death is greatest in the habitually least physically active individuals. No strategies have been adequately studied to evaluate their ability to reduce exercise-related acute cardiovascular events. Maintaining physical fitness through regular physical activity may help to reduce events because a disproportionate number of events occur in least physically active subjects performing unaccustomed physical activity. Other strategies, such as screening patients before participation in exercise, excluding high-risk patients from certain activities, promptly evaluating possible prodromal symptoms, training fitness personnel for emergencies, and encouraging patients to avoid high-risk activities, appear prudent but have not been systematically evaluated.

Cardiac rehabilitation secondary prevention programs

Contemporary cardiac rehabilitation programs are more accurately described as "secondary prevention centers." They offer comprehensive care for the patient with cardiovascular disease, resulting in decreased mortality, improvement of most cardiac risk factors, and an enhanced quality of life. Although overall participation has increased with enhanced recognition of the importance of secondary prevention, 80% of eligible patients still do not participate, in part due to lack of insurance reimbursement. This rate can be significantly increased by specific endorsement from the physician.