Defibrillator Debate

April 4, 2001
Does a life-saving emergency defibrillation program begin or end with AEDs?

In February, a sports reporter at a major East Coast newspaper suffered a sudden cardiac arrest (SCA) in the newsroom. Co-workers rushed to his aid and applied an automatic external defibrillator (AED). The AED diagnosed his condition and delivered a life-saving shock. At first glance, it appears that the reporter was saved by a miracle of modern technology -- the AED. In part, he was. The whole story of how a life was saved, however, involved much more than the AED.

The reporter was saved because the newspaper had instituted a comprehensive program that included an AED and first aid supplies positioned close by, employees who knew how to activate their emergency defibrillation plan and trained volunteers who could respond to the emergency.

When sudden cardiac arrest (SCA) strikes, time is essential. According to the American Heart Association, survival rates drop dramatically, up to 10 percent, for every minute that passes before a shock is applied. The New England Journal of Medicine documented a study that shows three out of four SCA victims could be saved if trained employees retrieve the AED, get to the victim and apply the shock within 3 minutes. There is no room for error. Hitting that window takes planning, preparation and the right training.

In the newspaper's case, that preparation started by viewing the AED as part of a total workplace SCA response system. The program includes strategically located AEDs to reduce response time, trained workers who can confidently respond to an emergency and know-how to use the AED, well-maintained equipment and a program that meets federal and state requirements. Their program was complete, which allowed them to respond quickly, competently and, most important, effectively to the emergency.

Complient, which has helped organizations implement nationwide AED-based emergency defibrillation systems, follows eight steps to analyze needs, then implement and manage the program. These steps enable organizations to determine AED placement, select and train workplace responders, choose and maintain equipment, and comply with federal, state and local regulations.

1. Manage the Project

Designing and implementing an emergency defibrillation program is similar to every other major safety initiative. Each requires that you determine the risk for your organization; develop plans, policies and programs to address the issue; implement those plans with training and equipment; document and analyze data generated by the program; and, finally, manage all aspects of the program on a day-to-day basis.

A project manager should be assigned who is responsible for implementing and tracking an AED program from start to finish. To properly implement the program, the manager must look at all aspects, not just equipment or training. The project manager's responsibilities include providing on-going training, developing routine equipment maintenance procedures, tracking medical supplies, monitoring state and federal regulations, and documenting the program every step of the way.

2. Conduct Site Assessments

Performing a site assessment provides the basic information needed to build your program. How many devices are needed in each facility? Where should these devices and other emergency equipment and supplies be located? How many workplace responder teams will you need to recruit at each facility? What type of training will they require? These questions can be answered in a site assessment.

The determining factor for placing AEDs is response time. The shorter the interval between the SCA (the drop) and the application of the AED (the shock), the greater the chance that a victim will survive.

Place AEDs in highly visible, prominent and accessible locations, such as near interior doorways and stairway landings. The objective is to ensure that, no matter where an SCA occurs within your facility, a response team will be able to reach the victim, begin CPR, apply an AED, diagnose the patient and deliver a shock -- all within 3 minutes.

3. Create Workplace Responder Teams

AEDs are easy to use -- one study indicates that a sixth-grader can operate one. In an emergency, however, many additional issues may emerge. Saving a life may require CPR and first aid, and may expose a Good Samaritan to bloodborne pathogens. For these reasons, you cannot expect an untrained bystander to respond effectively and safely in an emergency.

The recruitment and establishment of workplace responder teams protects the organization from liability and ensures a quick and effective response to any emergency. While most workplace responders are not trained medical personnel, experience shows they can effectively bridge the gap until a local emergency medical services (EMS) team arrives. Organizations with trained medical personnel are a step ahead if they assign those employees to AED workplace responder teams.

Just as response time dictates where AEDs are placed, coverage dictates the number of workplace responder teams needed. A response team made up of employees who work within the 3-minute "drop-to-shock" area around each AED location is needed for each shift. A response team's duties are to access the AED and other emergency medical equipment, go to the site and assess the victim, make sure 911 is called and begin treatment.

4. Train Workplace Responder Teams

Recruiting workplace responder teams and training them is truly what separates life-saving AED programs from those that simply place a unit on a wall and hope. When an employee suffers an SCA, a fall may result in additional injuries. For example, he may hit his head on his desk, causing an open head wound. Suddenly, there are more issues with which to be concerned. For these reasons, training on five basic topics is necessary.

1. CPR. The American Heart Association's "Chain of Survival" concept for emergency cardiac care includes early CPR because it is integral to saving the life of an SCA victim. CPR is used in conjunction with the AED and may be applied, even when a shock is indicated, to resuscitate a victim.

2. AED training. It is important to integrate CPR and AED training so that workplace responders can properly treat a victim. AED training encompasses the operation of an AED,

as well as victim preparation procedures and procedures for using an AED with CPR.

3. Emergency oxygen administration. Providing oxygen to a victim is critical when responding to an SCA. A lack of oxygen in the victim's bloodstream can blunt the effects of an AED. Providing oxygen is also one of the most basic procedures in all emergency situations as it used to effectively treat shock.

4. Bloodborne pathogens training. Bloodborne pathogens training teaches workplace responders how to protect themselves and others. OSHA requires bloodborne pathogens training for designated first aid responders.

5. First aid. First aid training is critical when reacting to an emergency situation. While workplace responders are trained to treat SCA, they often encounter other situations. First aid training puts responders in the best position to support injured people.

Professionals chosen to train workplace responders should be capable of providing consistent, standardized training among all facilities. Training should meet American Heart Association (AHA) guidelines along with state and local regulations, and they should be AHA-trained, professional educators with experience in emergency trauma situations. Finally, they should offer optimum skill development and retention for workplace responders through hands-on repetition.

Tracking training records is important. CPR, AED, first aid and bloodborne pathogens (BBP) certifications expire in one- to three-year intervals, depending on the course. Turnover of staff should also be considered, as training will need to match churn rates. While all workplace responders are on the same page at the outset of a program, everyone eventually will end up at a different level. Continuously track responder teams to compensate and ensure that they have up-to-date credentials and can respond to the emergency. Documentation also proves that responders participated in the training programs and that they were trained consistently.

5. Select Equipment and Supplies

Responders should not only have AEDs available, they should also have equipment and supplies available to treat the highest percentage of emergencies possible. They should be packaged together so responders do not waste valuable time making decisions about what to take to the victim.

Medical supplies needed for an AED-based emergency response kit include:

1. AED and electrodes. The same AED model should be used throughout the organization to limit confusion on its use and maintenance.

2. Victim prep kit. Have on hand supplies to cut away clothing and ensure adhesion of electrodes.

3. CPR audio prompt. Recognizing that CPR can be difficult to learn, remember and perform, AHA encourages the use of CPR audio prompts where CPR is performed infrequently.

4. Emergency oxygen. Providing mouth-to-mask rescue breathing is a start, but an emergency oxygen unit in conjunction with rescue breathing is more effective.

5. First aid kit. Often, victims of SCA injure themselves as they fall. In cases where an SCA did not occur, but first responders are called, the first aid kit allows them to treat other injuries that may be present.

6. BBP protection and cleanup kits. Workplace response teams first have to protect themselves before they treat a patient. OSHA requires that employees know how to protect themselves from BBP and have the equipment necessary for protection and to clean up any contamination.

6. Maintain Equipment and Supplies

Equipment considerations do not end with the selection and acquisition of an AED and other medical equipment and supplies. All equipment and supplies must be maintained. Though AEDs are self-servicing in many ways, their batteries and the adhesive on their pads have limited life spans. Also, it is easy to forget about replacing pads, gloves and other medical supplies that have been opened or used.

After every incident, trained personnel should service all supplies and equipment. All equipment should be checked regularly to verify that all supplies are present. Expiration dates on supplies and equipment must be tracked and maintenance records kept.

7. Medical Requirements

AEDs are FDA-controlled devices. Federal guidelines state that they may only be used with a prescription from a physician who is licensed in the state where the AED will be located. If an organization has facilities in multiple states, it needs a physician licensed in each state to write a prescription for AEDs delivered to facilities in that state. Many states have laws that require medical oversight of an AED program. They may make a physician responsible for some or all of the following:

  • 1. Developing medical protocols that meet all state and local guidelines for the use of the AED;
  • 2. Overseeing and validating training programs to ensure protocols are followed;
  • 3. Supporting the program by answering clinical questions that come up; and
  • 4. Receiving and evaluating AED-recorded data and forwarding it to the appropriate agencies when an event occurs.

Medical protocols are administrative guidelines and response steps for the management of a workplace emergency. Establishing them for response teams ensures that victims receive the best possible care and that the organization's liability is reduced. Any AED protocol developed will need to be incorporated into other emergency protocols (fire, evacuation, earthquake, etc.), because SCAs may occur during these emergencies.

An AED protocol may include:

  • 1. An explanation of the responsibilities of each member of a response team;
  • 2. Guidelines for protection from bloodborne pathogens;
  • 3. Instructions on using a CPR audio prompt; and
  • 4. Post-incident data downloading guidelines.

All protocols developed for a program should be documented in a booklet or flier and distributed to responder teams.

8. Documentation and Recordkeeping

There are many project management benefits derived from documenting the de- sign, implementation and event outcomes of a workplace defibrillation program. The most pressing need, however, is to protect the company and workplace responders from legal issues.

To make the AED program most effective, share site assessment data, the locations of AEDs, emergency notification and response procedures, and contact information for the overseeing physician with the local EMS. Ultimately, the goal is to save lives. To this end, it is crucial to help trained medical professionals be more efficient and effective when they respond to an emergency.

Recording training, protocols, equipment maintenance and emergency response outcomes will allow an organization to monitor policies, procedures and training for consistency. By tracking this information, it is easier to schedule workplace responder coverage on all shifts; account for vacations, retirements and job changes; know when new responders need to be recruited and trained; and ensure that veteran workplace responders maintain their certifications.

From this complex, multistage process, it should be clear that buying an AED is not the end, but only the beginning, of a life-saving program. By implementing a complete AED-based emergency defibrillation program, an organization can protect its work force, limit liability and saves lives.

Robert I. Thompson is president and chief operating officer of Complient's Services Group, a nationwide pro-vider of health and safety consulting services and emergency medical response equipment. The Services Group implements and manages large, turnkey AED programs nationwide for business, health care and government organizations. Last year, it provided services to more than 15,000 organizations and trained 250,000 people in a variety of health and safety topics.

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