Use and coverage of automated external defibrillators according to location in out-of-hospital cardiac arrest

doi:10.1016/j.resuscitation.2021.01.040

Resuscitation

Volume 162, May 2021, Pages 112-119

https://doi.org/10.1016/j.resuscitation.2021.01.040 Get rights and content

Abstract

Aims

To evaluate 1) the relative use of automated external defibrillators (AEDs) at different types of AED locations 2) the percentage of AEDs crossing location types during OHCA before use 3) the AED coverage distance at different types of AED locations, and 4) the 30-day-survival in different subgroups.

Methods

From 2014–2018, AEDs used by bystanders during out-of-hospital cardiac arrest (OHCA) in the Region of Southern Denmark were collected. Data regarding registered AEDs was retrieved from the national AED-network. The OHCA site and AED placement was categorized into; 1) Residential; 2) Public; 3) Nursing home, 4) Company/workplace; 5) Institution; 6) Health clinic and 7) Sports facility/recreational. To evaluate 30-day-survival, groups 4–7 were pooled into one Mixed group.

Results

In total 509 OHCAs were included. There was high relative usage of AEDs from public places, nursing homes, health clinics and sports facilities, and low relative usage from companies/workplaces, residential areas and institutions. Of AEDs used during residential OHCAs 39% were collected from public places. AEDs placed in residential areas and public places had a coverage of 575 m (IQR 130–1300) and 270 m (IQR5-550), respectively. Thirty-day- survival in public, residential and mixed groups were 49%, 14% and 67%, respectively.

Conclusion

The relative use of AEDs from public places, nursing homes, sports facilities and health clinics was high, and AEDs used during OHCA in residential areas were most frequently collected from public places. AEDs placed in both residential areas and public places may have a wider coverage area than proposed in current literature.

Introduction

Cardiac arrest means abrupt cessation of cardiac activity and will inevitably lead to death if not treated immediately. Out of-hospital cardiac arrest (OHCA) is a major public health concern and annually strikes approximately 700,000 people in Northern America and Europe combined.¹ Early cardiopulmonary resuscitation (CPR) and defibrillation within the first minutes with an automated external defibrillator (AED) may increase survival to more than 50%.2, 3 In recent years, AEDs have gained widespread dissemination in many communities4, 5 and in Denmark several national initiatives have been undertaken to increase bystander AED use, including the establishment of a national AED-network.⁶ Bystander defibrillation, however, remains low ranging from 1 to 5%.5, 6, 7, 8 Prior studies have indicated that to increase AED use, AEDs must be placed in close proximity to the site of cardiac arrest,8, 9, 10 they must be available at all times10, 11, 12 and bystanders must be aware of AED locations and be willing to use them.¹³ Also, the most optimal AED placement appears to be in public places with high pedestrian traffic.12, 14 Indeed, AEDs are recommended to be placed in public places with high likelihood of OHCA that can be reached within 1–1.5 minutes of brisk walking or approximately 100 m.15, 16, 17 However, international recommendations regarding specific AED placement are scarce, resulting in unguided AED placement in most cases.6, 7, 18 So far, AED use from specific locations remains largely unknown. Also, data addressing the actual distances AEDs are carried to OHCA sites is limited, making it difficult to assess the coverage of AEDs placed at different locations.

The aim of this study was three-fold: 1) to assess the relative use of AEDs placed at different types of locations; 2) to assess whether AEDs are carried across different location types before they are used; and 3) to assess the AED coverage distances at different AED locations.

Section snippets

Settings and study design

This is a retrospective cohort study with prospectively collected data from AEDs used by bystanders in the Region of Southern Denmark from January 1st 2014 to December 31st 2018. The region is mixed rural-urban and covers an area of 12,191 km². It has 39 Emergency Medical Service (EMS) stations and one emergency medical dispatch centre (EMDC). The region has 1.2 million inhabitants. During the years 2009–2014, a total of 4350 OHCAs occurred in the region, resulting in 42.4 OHCAs per 100,000

Baseline characteristics and outcomes

During the study period, the AED-centre collected 621 AEDs. As illustrated in Fig. 1, 509 OHCA-patients fulfilled the inclusion criteria. Table 1 shows the demographic and prognostic results. OHCAs in public places and in the ‘Mixed’ group were more often male and more frequently had a witnessed cardiac arrest. Shockable first AED rhythm was less frequent in OHCAs in residential areas and nursing homes. Survival after OHCA in public places and the ‘Mixed’ group was three to four times higher

Discussion

This study presents novel data addressing real life use of AEDs in patients with OHCA from a mixed rural-urban area. A relative high use was observed of AEDs placed in public places and nursing homes, whereas a low use was observed in residential areas. The majority of AEDs were placed and used in the same type of location. Thirty-nine percent of AEDs used in residential areas were retrieved from public places. AEDs placed in residential areas and at public places had a median coverage distance

Conclusion

By collecting data from AEDs that were used during OHCAs in a mixed rural-urban area, we observed high AED use from public places, nursing homes, sports facilities/recreational areas and health clinics, and low use from companies/workplaces, residential areas and institutions. The majority of AEDs were placed and used in the same type of location, except for residential OHCAs, where AEDs more frequently were retrieved from public places. By measuring en-route distances from AED location to OHCA

Conflicts of interest

Doctor Møller has received grants and personal fees from Abiomed, and personal fees from Orion Pharma and Novartis. All other authors declared no conflict of interests.

CRediT authorship contribution statement

Laura Sarkisian: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Visualization, Project administration, Funding acquisition. Hans Mickley: Conceptualization, Methodology, Validation, Formal analysis, Writing - original draft, Writing - review & editing, Supervision, Project administration, Funding acquisition. Henrik Schakow: Conceptualization, Methodology, Investigation, Resources, Data curation,

Acknowledgements

We thank the health care professionals at the EMDC for the assistance in data acquisition and collaboration with the AED-centre. Also, we thank the AED-network for sharing data for the purpose of this study.

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Human exposure to high-altitude and/or low-temperature areas is increasing and cardiac arrest in these circumstances represents an increasing proportion of all treated cardiac arrests. However, little is known about the performance of automated external defibrillators (AED) in these circumstances. The objective of this study is to assess the functional and electrical features of 6 commercially available AEDs in extreme environments.
Accuracy of shockable rhythm detection, the time required for self-test, rhythm analysis, and capacitor charging, together with total energy, peak voltage, peak current, and phasic duration of defibrillation waveform measured after placing the AEDs in simulated high-altitude, simulated low-temperature, and natural composite high-altitude and low-temperature environment for 30 min, were compared to those measured in the standard environment.
All of the shockable rhythms were correctly detected and all of the defibrillation shocks were successfully delivered by the AEDs. However, the time required for self-test, rhythm detection, and capacitor charging was shortened by 1.2% (3 AEDs, maximum 12.4%) in the simulated high-altitude environment, was prolonged by 3.6% (4 AEDs, maximum 40.8%) in the simulated low-temperature environment, and was prolonged by 4.1% (5 AEDs, maximum 52.1%) in the natural environment. Additionally, the total delivered energy was decreased by 2.5% (2 AEDs, maximum 6.8%) in the natural environment.
All of the investigated AEDs functioned properly in simulated and natural environments, but a large variation in the functional and electrical feature change was observed. When performing cardiopulmonary resuscitation in extreme environments, the impact of environmental factors may need consideration.
PULS – Austrian Cardiac Arrest Awareness Association: An overview of a multi-tiered and multi-facetted regional initiative to save lives
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Out-of-hospital cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) still leads to dismal outcomes worldwide. The crucial gap between cardiac arrest and advanced life support can only be filled by bystander-CPR. However, knowledge and willingness of the public towards basic life support (BLS) remain low. Global and national initiatives for awareness building and CPR training have produced promising improvements, but an additional focus on regional initiatives might be necessary to truly implement change.
In order to support other like-minded groups, we present a “coming of age” narrative review of PULS – Austrian Cardiac Arrest Awareness Association, along with a future outlook and “lessons learned”. Interviews with past and present employees, members, and functionaries were conducted by the authors. Additionally, the organization’s archives were assessed.
Following current guidelines and the Utstein formula of survival, building a system to save lives is essential to achieve progress concerning cardiac arrest survival and outcomes. As kinds of “regional offices” of global resuscitation efforts, a network of individual local initiatives and organizations such as PULS can carry the respective messages, engage with local key figures of implementation, and keep up perpetual work for cardiac arrest awareness and BLS education.
Racial and ethnic disparities amongst patients with lay rescuer automated external defibrillator placement after out-of-hospital cardiac arrest
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This study evaluated the association between patient race/ethnicity and the odds of AED provision by a lay rescuer in out-of-hospital cardiac arrest (OHCA) in the United States.
This was a cross-sectional retrospective study of OHCA patients in the National Emergency Medical Services Information System database from the year 2021. Patients were excluded for age < 18 years, EMS-witnessed arrest, traumatic arrest, arrest in a healthcare setting, do-not-resuscitate order, and arrest in a wilderness location. The primary outcome was the association between race/ethnicity and the odds of lay-rescuer AED placement for OHCA. Multiple logistic regression adjusting for known covariates was performed and odds ratios were reported.
A total of 207,134 patients were included. Patients with lay rescuer AED use had statistically significant differences with regard to arrest location and arrest witnessed status, and had longer EMS response times (8.5 minutes vs 7 minutes). The odds of AED use was lowest for American Indian/Alaskan Native persons (OR 0.62; 95% CI 0.54, 0.72) followed by Asian (OR 0.66; 95% CI 0.60, 0.72), Hispanic (OR 0.66; 95% CI 0.63, 0.69) and Native Hawaiian/Pacific Islander patients (OR 0.69; 95% CI 0.57, 0.83) when compared to White patients. Black patients had the highest odds of AED use (OR 1.10; 95% CI 1.07, 1.12).
When compared to White persons, the odds of lay rescuer AED use in OHCA was between 31–38% lower for American Indian/Alaskan Native, Asian, Hispanic, and Native Hawaiian/Pacific Islander persons, and 10% higher for Black persons.
Bystander cardiopulmonary resuscitation, automated external defibrillator use, and survival after out-of-hospital cardiac arrest
2023, American Journal of Emergency Medicine
We aimed to investigate the association between bystander cardiopulmonary resuscitation (CPR) with and without automated external defibrillator (AED) use and neurological outcomes after out-of-hospital cardiac arrest (OHCA) in Korea.
This cross-sectional study used a nationwide Korean OHCA registry between 2015 and 2019. Patients were categorised into no bystander CPR and bystander CPR with and without AED use groups. The primary outcome was good neurological recovery at discharge. We also analysed the interaction effects of place of arrest, response time, and whether the OHCA was witnessed.
In total, 93,623 patients were included. Among them, 35,486 (37.9%) were in the no bystander CPR group, 56,187 (60.0%) were in the bystander CPR without AED use group, and 1950 (2.1%) were in the bystander CPR with AED use group. Good neurological recovery was demonstrated in 1286 (3.6%), 3877 (6.9%), and 208 (10.7%) patients in the no CPR, bystander CPR without AED use, and bystander CPR with AED use groups, respectively. Compared to the no bystander CPR group, the adjusted odds ratio (95% confidence intervals) for good neurological recovery was 1.54 (1.45–1.65) and 1.37 (1.15–1.63) in the bystander CPR without and with AED use groups, respectively. The effect of bystander CPR with AED use was more apparent in OHCAs with witnessed arrest and prolonged response time (≥8 min).
Bystander CPR was associated with better neurological recovery compared to no bystander CPR; however, the benefits of AED use were not significant. Efforts to disseminate bystander AED availability and ensure proper utilisation are warranted.
Longer retrieval distances to the automated external defibrillator reduces survival after out-of-hospital cardiac arrest
2022, Resuscitation
Citation Excerpt :
However, evaluating the effect of AED retrieval distance on survival can be addressed exclusively in an observational context; 2) OHCAs in nursing homes were excluded as these markedly differ regarding age, comorbidity and prognosis compared with OHCAs outside of nursing homes.25,41 Furthermore, in nursing homes, OHCA and AED location have the same address,25 which could affect the regression analysis, when evaluating survival in relation to AED retrieval distances; 3) the number of used AEDs that did not reach the AED-center is not available. However, in the event of AED deployment, the EMDC is required to inform both the AED-centre and EMS staff to ensure transportation to the AED-centre, which should limit this issue.
To evaluate and compare survival after out-of-hospital (OHCA), where an automated external defibrillator (AED) was used, in densely, moderately and thinly populated areas. Also, to evaluate the association between AED retrieval distance and survival after OHCA.
From 2014 to 2018, AEDs used during OHCA in the region of Southern Denmark were systematically collected. OHCAs were included if the OHCA address was known. OHCAs at nursing homes were excluded. To evaluate population density, a map with 1000 × 1000 meter grid cells was used with each cell color-graded according to the number of inhabitants. Densely, moderately and thinly populated areas were defined as ≥200 inhabitants, 20–199 inhabitants and 0–19 inhabitants per km², respectively. Primary outcome was 30-day survival.
A total of 423 cases of OHCA were included, of which 207 (49%) occurred in densely populated areas, while 78 (18%) and 138 (33%) occurred in moderately and thinly populated areas, respectively. AED retrieval distances were: densely populated 105 m (IQR 5–450), moderately populated 220 m (IQR 5–450) and thinly populated 350 m (IQR 5–1500) (P < 0.001). Thirty-day survival was 40%, 31% and 34%, respectively (P = 0.3). In a multivariable regression analysis, mortality increased with 10% per 100 m an AED was placed further away from the site of OHCA.
Survival after OHCA, where an AED was used, did not seem to differ in thinly, moderately and densely populated areas. The length of the AED retrieval distance, however, was correlated with reduced survival after adjusting for other potentially explanatory variables.
Reply to: Singularities of AED implementation in occupational setting and COVID-19 pandemic
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Clinical paperUse and coverage of automated external defibrillators according to location in out-of-hospital cardiac arrest

Abstract

Aims

Methods

Results

Conclusion

Introduction

Section snippets

Settings and study design

Baseline characteristics and outcomes

Discussion

Conclusion

Conflicts of interest

CRediT authorship contribution statement

Acknowledgements

Resuscitation.

J Am Coll Cardiol.

Resuscitation.

J Am Coll Cardiol.

Resuscitation.

Am J Cardiol.

Resuscitation.

Resuscitation.

Resuscitation.

Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos

N Engl J Med.

Public use of automated external defibrillators

N Engl J Med.

Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan

N Engl J Med.

Bystander Defibrillation for Out-of-Hospital Cardiac Arrest in Public vs Residential Locations

JAMA cardiology.

Identifying locations for public access defibrillators using mathematical optimization

Circulation.

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

Eur Heart J Acute Cardiovasc Care.

Clinical paper
Use and coverage of automated external defibrillators according to location in out-of-hospital cardiac arrest