American College of Emergency Physicians
The American College of Emergency Physicians (ACEP) believes that the efficacy of early defibrillation with the reliable technology of current automatic external defibrillators (AEDs) is proven and widely accepted within the out-of-hospital provider community. However, before early defibrillation programs can be promoted in a widespread manner, they must be integrated into or coordinated with EMS systems that are designed to maximize the potential for survival in the ventricular fibrillation victim.
AEDs should be carried by all basic life support ambulances. AEDs should also be available to Medical First Responders such as police and fire personnel and to other designated first responders in highly congested population areas.
ACEP endorses the widespread availability of AEDs and the implementation of early defibrillation programs coordinated with an EMS delivery system to ensure the following:
- Immediate activation of the EMS system for the ventricular fibrillation victim
- Immediate delivery of CPR
- Early defibrillation by the first designated responder to arrive on the scene
- Timely provision of advanced life support
- Rapid transport to an emergency medical facility
- Medical direction of all components including the AED program
All of these factors are critical to ensure that the EMS personnel can optimally treat victims of cardiac arrest. Appropriate monitoring of quality of care and outcomes must occur. Legislation may be necessary in some locations to allow for Medical First Responders to use AEDs.
Policy Number 400202
Approved by the ACEP Board of Directors, June 1999
American College of Occupational and Environmental Medicine (ACOEM)
The American College of Occupational and Environmental Medicine (ACOEM) supports the establishment of programs by employers to use automated external defibrillators (AEDs) to manage sudden cardiac arrest in workplace settings. ACOEM supports ongoing efforts to enhance emergency response to medical emergencies in the occupational environment.
The College has thus developed a guideline to increase the awareness of the value of AEDs and has presented recommendations to encourage and provide guidance on their use in the workplace. This guideline reviews the following topics: (1) epidemiology, morbidity, and mortality of cardiovascular diseases in the workplace; (2) the "chain of survival" paradigm; (3) history and descriptions of AEDs; (4) standard-of-care interventions and guidelines; (5) public-access defibrillation and federal initiatives; and (6) reommendations for establishing and managing a workplace AED program.
Development of programs to utilize AEDs is a reasonable and appropriate aspect of such programs to manage sudden cardiac arrest, an important cause of morbidity and mortality among working age adults. Implementation of such an AED program, which should be a component of a more general worksite emergency response plan, requires clearly defined medical direction and medical control.
Prepared under the auspices of the Council on Scientific Affairs, peer-reviewed by the members of the Council and approved by the ACOEM Board of Directors on February 11, 2001.
American Heart Association
"It is essential to integrate the concept of early defibrillation into an effective emergency cardiac care system. This is best characterized by the "Chain of Survival" concept, which includes early access to the emergency medical services system, early cardiopulmonary resuscitation when needed, early defibrillation when indicated, and early advanced care. To achieve the goal of early defibrillation, the American Heart Association endorses the position that all emergency personnel should be trained and permitted to operate an appropriately maintained defibrillator, if their professional activities require that they respond to persons experiencing cardiac arrest. This includes all first responding emergency personnel, both hospital and non-hospital (e.g., non-EMT first responders, firefighters, volunteer emergency personnel, emergency medical technicians, paramedics, nurses and physicians). To further facilitate early defibrillation, it is essential that a defibrillator be immediately available to emergency personnel responding to a cardiac arrest. Therefore all emergency ambulances and other emergency vehicles that respond to or transport cardiac patients should be equipped with a defibrillator." Circulation 1991;83(6):2233.
Public Access Defibrillation : A Statement for Healthcare Professionals From the American Heart Association Task Force on Automatic External Defibrillation
"Early bystander cardiopulmonary resuscitation (CPR) and rapid defibrillation are the two major contributors to survival of adult victims of sudden cardiac arrest. The AHA supports efforts to provide prompt defibrillation to victims of cardiac arrest. Automatic external defibrillation is one of the most promising methods for achieving rapid defibrillation. In public access defibrillation, the technology of defibrillation and training in its use are accessible to the community. The AHA believes that this is the next step in strengthening the Chain of Survival. Public access defibrillation will involve considerable societal change and will succeed only through the strong efforts of the AHA and others with a commitment to improving emergency cardiac care.
Public access defibrillation will include:
- Performance of defibrillation by laypersons at home and by firefighters, police, security personnel, and nonphysician care providers in the community
- Exploration of the use of bystander-initiated automatic external defibrillation in rural communities and congested urban areas where resuscitation strategies have had little success.
The AHA can also play a major role by:
- Increasing public awareness that defibrillation improves the rate of survival from an often fatal condition that each day affects 1,000 Americans
- Ensuring that objective, current research data are used to guide implementation of these changes in performance and teaching of CPR
- Working with medical manufacturers, legislators, and governmental agencies to promote safety and efficacy, reduce cost, and update training requirements to facilitate implementation of public access defibrillation. Broader use of automatic external defibrillators should also lead to readiness tests and features that deter both misuse and misapplication. Meaningful change will occur only with the broad public support that has traditionally characterized the AHA's efforts in the fight against heart disease and stroke." Circulation 1995;92:2763.
American Public Health Association, Injury Control Section Recommendations for Healthy People 2010
"By 2010, all prehospital EMS personnel will be trained in the use of the automatic external defibrillator. Rationale: Most EMS personnel now have AEDs in their training, but many, especially "first responders" do not. In order to reach peak public health efficacy, AEDs need to be available, with people who know how to use them, within four minutes response time to cardiac arrest victims."
The American Red Cross
"The American Red Cross supports legislation and other government action at the local, state and federal levels to encourage mandatory training in Automatic External Defibrillation (AED) for individuals who have legal responsibility to provide emergency care, including fire fighters, police, emergency medical personnel and lifeguards. AED is an automatic device used to recognize a fatal heart rhythm that requires a shock and either delivers the shock or prompts the rescuer to deliver. In addition, the American Red Cross supports the expansion of AED training to the general public for people that may have a need -- such as individuals who have family members with cardiac problems. The Red Cross supports legislation to ensure access to emergency medical services and that AEDs should be available at public access sites such as office buildings, stadiums, arenas, and other sites where large numbers of the public gather." December 1997.
Canadian Association of Emergency Physicians Public Access Defibrillation Working Group
"Out-of-hospital sudden cardiac arrest, caused by ventricular fibrillation, is a leading cause of death in Canada. The most effective treatment available to out-of-hospital victims of sudden cardiac arrest is early defibrillation. Experience has shown that targeted responders (e.g., police, security personnel, flight attendants) can learn to use an automated external defibrillator (AED) safely and effectively. The Canadian Association of Emergency Physicians (CAEP) believes that Public Access Defibrillation (PAD) programs, through targeted responders using AEDs, have the potential to improve survival from out-of-hospital cardiac arrest."
CAEP also believes that:
- Scientific research and physician direction are required to determine the safety, success and cost-effectiveness of targeted responder PAD programs, and of PAD programs where lay responders function in less structured settings;
- Provincial regulations or legislation should ensure immunity from civil liability for:
- a PAD responder who renders emergency care through the use of an AED (for any personal injury as a result of such care, or failure to provide such care),
- an entity that provides training of PAD responders,
- a physician who provides medical direction for a PAD program,
- a person or entity who purchases and deploys an AED for a PAD program, provided that the personal injury does not result from individual or PAD program gross negligence or willful or wanton misconduct;
- PAD programs should meet or exceed existing guidelines, developed by recognized provincial or national emergency cardiac care organizations, for AED and CPR training and skill maintenance;
- PAD programs should be coordinated with local, regional or provincial emergency medical services (EMS) authorities to ensure:
- compatible patient transfer-of-care protocols,
- that community AEDs are registered with the EMS authority,
- a written, on-site emergency response protocol to rapidly activate the PAD responder and early 911 notification in the event of a cardiac arrest;
- Physician direction is required to oversee development and authorization of the following PAD program elements:
- patient treatment protocols,
- PAD responder training and skill maintenance,
- collection, storage and transfer of clinical data to the EMS authority to allow for continuous surveillance of community cardiac arrest management and outcomes,
- a quality assurance program to review each case where an AED is applied to a patient;
- A plan for continual AED readiness-for-use and maintenance must be in place according to the AED manufacturer's operational guidelines;
- The principle of continuity of EMS patient care must be maintained to ensure that once 911 is called, every patient treated under a PAD program becomes the responsibility of EMS personnel, the EMS system and the EMS system's medical directors.
- Targeted responder: A person trained in AED use, under a PAD program, who normally has a duty to respond to and perform CPR on a victim of out-of-hospital cardiac arrest. (e.g., police, security guards, flights attendants, lifeguards, first aid officers)
- Lay responder: A person trained in AED use, under a PAD program, who does not normally have a duty to respond to and perform CPR on a victim of out-of-hospital cardiac arrest (e.g., store clerks, ushers, secretarial staff, janitorial staff, personal care attendants)
Citizen CPR Foundation
"The Citizen CPR Foundation urges all communities to implement and monitor effective emergency cardiac care systems that address each link in Chain of Survival. This includes early defibrillation capabilities ensure personnel trained capable providing can arrive at victim's side within minutes arrest." (Excerpt.) Currents 1993;4(4).
Citizen CPR Foundation
"The Citizen CPR Foundation urges all communities to implement and monitor effective emergency cardiac care systems that address each link in Chain of Survival. This includes early defibrillation capabilities ensure personnel trained capable providing can arrive at victim's side within minutes arrest." (Excerpt.) Currents 1993;4(4).>http://www.citizencpr.org/position1.shtml
Emergency Care Research Institute
"The American Heart Association recommends that response times to a cardiac arrest average no more than two minutes in a specific hospital location. However, in most hospitals, extensively trained, specially designated resuscitation or code teams respond to cardiac arrest using conventional manual defibrillators. Although response times in hospitals often are perceived as being short, studies have shown that in some hospitals, delays greater than five minutes can occur before in-hospital response teams deliver the first shock. According to ECRI, dissemination of AEDs in multiple locations throughout the hospital and training in their use by additional hospital personnel could reduce response times and increase survival rates."
"AEDs may be particularly advantageous in settings where delays in response times are likely to occur. These include noncritical areas and outpatient and diagnostic facilities where staff are not trained to respond to cardiac emergencies. With two hours training, noncritical care nurses can learn and retain the knowledge and skills necessary to use AEDs."
Heart & Stroke Foundation of Canada ECC Coalition Task Force
"The health care system has the responsibility to ensure early defibrillation (8 to 10 minutes from collapse) as an accepted standard of care and that appropriate resources should be available to permit early defibrillation for all."
Heart and Stroke Foundation of Canada
"Public Access to Defibrillation: A Statement from the AED Taskforce
The Heart and Stroke Foundation of Canada recommends that:
- Early defibrillation initiatives be implemented within the community Chain of Survival.
- Targeted responders be authorized, trained, equipped and directed to operate an AED if their responsibilities require them to respond to persons in cardiac arrest.
- The implementation of an AED program must be linked with the emergency medical services system and implemented within systems which provide medical oversight, training, quality assurance, data collection and evaluation.
- Hospitals are encouraged to examine their policies and procedures for cardiac arrest and resuscitation to determine if utilization of AEDs within the hospital setting could reduce time to defibrillation. In settings where professionals trained in advanced life support are not immediately available, AED training should be provided as a basic skill for designated healthcare providers.
- Family members or companions of individuals at high risk for a cardiac event may choose to be trained to use AEDs under the direction of a physician.
- At this time, efforts should be directed to strengthening the Chain of Survival and ensuring access to AEDs by targeted responders in all Canadian communities. In the future, efforts to expand the use of AEDs by bystanders may be warranted."
International Association of Chiefs of Police and International Association of Fire Chiefs
"Whereas, medical experts have determined that the sooner a heart attack* victim can be defibrillated, the greater chance the victim will survive; and
Whereas, police officers are often the first emergency personnel to arrive on the scene of a heart attack* victim; and
Whereas the medical industry has developed automated external defibrillators that can allow non-medical personnel to safely and effectively defibrillate heart attack* victims; and
Whereas the use of automatic external defibrillators by police officers could result in the saving of countless; and
Whereas the American Heart Association has endorsed the concept of equipping police offers and other public safety first response personnel with automatic external defibrillators; and
Whereas both the International Association of Chiefs of Police and the International Association of Fire Chiefs are organizations dedicated to ensuring that both police and fire-fighting agencies have the equipment necessary to protect and assist the public; now, therefore be it
Resolved, that the leaders of the International Association of Chiefs of Police and the International Association of Fire Chiefs work together to promote the used of automatic external defibrillators by police and firefighters.
The International Association of Chiefs of Police, Inc., 1997
*The phrase "heart attack" should be replaced by the phrase "sudden cardiac arrest" throughout this document. (NCED commentary)
International Association of Fire Chiefs See International Association of Chiefs of Police.
International Association of Fire Fighters "It would be medically optimal if every community in North America were covered by fire fighter first responders who are trained and equipped to defibrillate and who arrive in less than five minutes."
International Liaison Committee on Resuscitation "To achieve the earliest possible defibrillation, the International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings nonmedical individuals should be allowed and encouraged to use defibrillators. ILCOR recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first-responding emergency personnel, in both the hospital and out-of-hospital settings, whether physicians, nurse or nonmedical ambulance personnel. The widespread availability of automated external defibrillators (AEDs) provides the technological capacity for early defibrillation by both ambulance crews and lay responders." Circulation 1997;95:2183-2184.
The National Association of EMS Physicians
"Sudden cardiac death is a major public health problem, claiming as many as 350,000 lives each year in the United States. Many who suffer sudden cardiac arrest can be successfully resuscitated if certain critical actions such as 9-1-1 access, bystander cardiopulmonary resuscitation, rapid defibrillation and prehospital advanced life support, are accomplished in a timely and effective manner. Since rapid defibrillation is the most critical of these interventions, strategies to enhance survival should focus on reducing the interval from collapse to defibrillation.
The development of the automated external defibrillator (AED) has made it feasible to train and equip basic level emergency responders with defibrillators and thus make early defibrillation more readily achievable. Available data indicate that AEDs can generally be effective when used by traditional (EMS & fire service) and some non-traditional (police, security, or flight attendant), first responders.
Increased survival has been postulated if other non-traditional first responders (building managers or health club employees, for example) and minimally trained or untrained bystanders have access to AEDs. The use of AEDs by this group is a concept that holds promise, despite insufficient data to demonstrating effectiveness or safety. One important concern is that providing these groups with access to AEDs could result in potential delays in activation of the EMS system that may be detrimental to patient outcome.
The Vision of NAEMSP is that all victims of sudden cardiac arrest should have rapid defibrillation available. Each community must perform a needs assessment and make appropriate resource allocations to identify optimal AED deployment strategies. To explore the role of nontraditional AED providers, NAEMSP strongly encourages continuing scientific studies of the effectiveness, safety and costs of AED programs. To enable cost-effective and appropriate public health policy decisions, cardiac arrest should be subject to the same epidemiologic scrutiny as are other reportable public health events.
Making AEDs available to non-traditional responders or minimally trained or untrained bystanders may be an effective strategy for achieving early defibrillation in certain communities. Regardless of the deployment strategy, there must be strong medical direction for each AED program and each community must also assure these AED programs are integrated into the local EMS system and included in quality assurance activities. Integration of AED programs into existing EMS systems is essential to ensure there are minimal delays in activating and transitioning care to the EMS system. State and federal governments must support persons who do not have a 'duty to respond' by developing or revising Good Samaritan laws to protect them from liability for good faith use of AEDs."
Approved by the NAEMSP Board of Directors, January 2000.
The National Association of State Emergency Medical Services Directors
"Sudden cardiac arrest is a major public health problem that ultimately must be addressed in individual communities and states through a data driven needs assessment and appropriate resource allocation...NAEMSD pledges to work cooperatively with other national organizations such as the American Heart Association and American Red Cross, to ensure that all our citizens have access to early defibrillation programs that are effective and safe."
National Council of State EMS Training Coordinators, Inc.
"...Whereas the National Council of State EMS Training Coordinators, Inc., is a major player in the "chain of survival" and promotes the training of EMS providers in early defibrillation, now therefore be it resolved, that the National Council of State EMS Training Coordinators, Inc., urges the American Heart Association and its affiliates and state EMS offices to work together in addressing concerns with the AHA proposed implementation plans for public access defibrillation within states."
National Heart, Lung and Blood Institute
"Early defibrillation of cardiac arrest victims is essential. The earlier the victim is defibrillated, the greater the chance of survival. Automated external defibrillators now make it possible for basic level emergency medical technicians and first responders-as well as paramedics-to defibrillate reliably and safely. Consequently, all EMS personnel, including first responders, should be trained to operate AEDs and all emergency medical vehicles should be equipped with defibrillators (manual or AEDs)." National Heart Attack Alert Program, Staffing and Equipping EMS systems: Rapid identification and treatment of acute myocardial infarction, NIH Publication No. 93-3304, 1993.
Positions Statements Advising Caution
American Association of Occupational Health Nurses (AAOHN)
"RATIONALE Since the introduction of cardiopulmonary resuscitation more than 35 years ago, few improvements have resulted in significantly improved outcomes other than the advent of early defibrillation (Weil & Tang, 1997). New defibrillation devices have been developed which allow the device to sense the need for defibrillation. These devices, sometimes called "smart defibrillators" or automatic external defibrillators (AEDs), are beginning to be utilized by emergency services providers and also in limited occupational settings. A number of airlines have incorporated the use of AEDs in wide-body airplanes for long flights, where access to sophisticated medical services is difficult. Legislation mandating that aircraft be equipped with at least one piece of lifesaving equipment (such as an AED) for use in responding to a cardiac emergency has also been introduced in Congress. Clearly, as AED use becomes more widespread, implications for the occupational health setting will be evident.
Early access defibrillation must be combined with other elements of the American Heart Association's "Chain of Survival"-early access, early CPR, and early access to Advanced Cardiac Life Support (ACLS). In cities where CPR training is widespread and EMS response is rapid, the survival rate increased from nine percent to 30 percent when AEDs were available to first responders (American Heart Association, 1998). Although geared toward emergency medical services delivery systems, AAOHN recognizes the American College of Emergency Physicians' guidelines for early defibrillation programs as a beginning framework for the necessary components of an effective AED program. These components include designation of AED providers, an education program, a program coordinator, and a quality improvement program (American College of Emergency Physicians, 1992). However, any workplace AED program should include an on-site designated program coordinator. One important function of the program coordinator is to ensure that the devices are in working order. AAOHN believes that the occupational health nurse provides the continuity necessary for the provision of an effective and efficient occupational health and safety program. In this same regard, the occupational health nurse is the ideal candidate to manage a worksite AED program.
Because of the life-saving potential of these devices, a number of forces are ambitiously working to rapidly incorporate these devices in the occupational setting. AAOHN is particularly concerned about the current lack of data on the necessary educational training requirements for responders utilizing AEDs. In addition, more research is needed on the efficacy of these devices. Policy issues must also be addressed related to the use of these devices. Enabling legislation to allow first responders to be able to use these devices must occur at the state level. Good Samaritan laws need to be examined and or amended, if necessary, to ensure liability protections for volunteer users of the devices. Furthermore, FDA approval is still pending on many of these devices. For these reasons, AAOHN believes that more information and research is needed prior to widespread use of these devices at the worksite. At the very least, companies utilizing these devices need to have an AED program in place, which includes a designated program coordinator, an education program to train users of the devices, and a quality improvement program."