Defibrillator Decision

By Richard LaRue

A noticeable increase in ink used to cover an issue or subject is one way to catch and prepare for trends. One issue that's making the rounds in the mainstream press is the AED, or Automated External Defibrillator.


The Washington Post reports, as part of an article about AEDs in health clubs, "Although firm data are not available, extrapolations from a few studies suggest that at least 1,500 Americans die each year after collapsing in health clubs, country clubs and other athletic venues."

And, in this increasingly litigious culture, there are emerging legal precedents and legislation that may impact our use of AEDs in public venues. As noted in the Washington Post article, "The fitness industry's wariness [about installing AEDs throughout their facilities] arises in large part from a fear that installing defibrillators will expose clubs to lawsuits if someone dies after the device is used, officials say.

Ironically, however, the few lawsuits involving AEDs have all been against organizations that did not have them."

Jonathan Masone, deputy commissioner with the Town of Hempstead, N.Y., Department of Parks and Recreation, reports that in the State of New York, bill #A-8779-A was passed, making it mandatory for any school with more than 1,000 students to have an accessible AED any time the school is open. The parents of a ninth grader, who was hit in the chest with a lacrosse ball and died on the field, lobbied for this bill.

The purpose of this bill was twofold... First, AEDs would be accessible for any emergency that occurred during the school day to students and staff. Second, that it would be accessible for any after school sports team on campus or off campus.

Schools in the State of New York that have AEDs, regardless of their student populations, must have an approved procedure by the State Department of Education. State law has mandated that educational systems be required to train, implement and ensure that the AED equipment is accessible at all times.

AEDs are arguably the hottest item in acute care of injury and illness in the United States. A quick review of the several recent policy decisions regarding professional and public access to AEDs should serve as sufficient notice for public and private recreational and sport organizations, to consider affording at least their properly trained staff, access to an AED.

AED Rundown
Applicable organizations are nearly endless, but for the purpose of this article, they include camps, parks and recreation departments, sports and fitness venues, YMCAs, YWCAs, Boys and Girls clubs, community recreation centers, youth and adult sport programs (especially those programs with Certified Athletic Trainers who are required to be trained in the use of AEDs), and other comparable recreation and leisure providers.

Automated External Defibrillators are typically about the size of a laptop, portable, and uniquely capable of analyzing a victim's heart for abnormalities in rhythm.

When necessary, the AED will direct a rescuer (sometimes in a single-step process) to deliver an electrical shock. This AED-produced shock is the third step in a critical four-step process known as the Cardiac Chain of Survival:

• Step one: Early access to care (calling 911 or another emergency number)

• Step two: Early cardiopulmonary resuscitation (CPR)

• Step three: Early defibrillation

• Step four: Early advanced cardiac life support as needed

Delivered correctly after performing the first two steps, the third step, or early defibrillation (delivering an electrical shock to the heart), "…is recognized as the most critical step in restoring cardiac rhythm and resuscitating a victim of sudden cardiac arrest. This shock, called defibrillation, may help the heart to reestablish an effective rhythm of its own."

Currently, the National Athletic Trainers' Association (NATA) has posted on its Web site an Official Statement regarding AEDs. This statement is based upon research regarding sudden cardiac arrest in infants, children and adolescents and statistics published by the American Heart Association regarding heart disease and stroke statistics.

Specifically, NATA states that the treatment of sudden cardiac arrest should be a priority among certified athletic trainers (ATCs). Further, the NATA states, "An AED program should be part of an athletic trainer's emergency action plan."

If you are wondering why your organization should be concerned about AEDs when it may have nothing to do specifically with organized sports or camps (a common place for an ATC), read on!

Any organization that is about programming for and/or enabling physical activity, or any organization that might have responsibility for the care of program participants or venue users in a health emergency, should consider the following statistics:

• Approximately 250,000 Americans die of sudden cardiac arrest (SCA) outside of the hospital.

• As many as 7,000 children die of SCA each year.

• In communities where shocks from an AED and Cardiopulmonary Resuscitation (CPR) are provided within 3-5 minutes by the first person on the scene, survival rates are as high as 48-74 percent.

In its Position Statement, NATA also encourages athletic trainers "…to make an AED part of their emergency equipment. In addition, in conjunction and coordination with a local Emergency Medical System (EMS), athletic trainers should take a primary role in implementing a comprehensive AED program within their work setting."

The fact is that an automated external defibrillator can deliver a life saving shock to the heart (when used correctly), "…making it the single most effective treatment for cardiac arrest."

For those organizations that are concerned about the use of AEDs for children under the age of eight, the American Heart Association, in a published statement (2003), recommends the use of AEDs for children ages one to eight. Prior to this statement AEDs were only approved for those eight and older, outside of a hospital setting.

However, AEDs have been found to accurately diagnose a child's heart rhythm (as well as an adult's), so that only those requiring a shock will have one administered.

And, AEDs can be operated by "…bystanders or emergency responders such as paramedics or police officers." One caution is that AEDs are not to be used on children under the age of one.

AED Access
The AHA and NATA are not the only organizations encouraging utilization or recommending that AEDs be made more readily available.

The U.S. Department of Labor, Occupational Health and Safety Administration (OSHA), in its Technical Information Bulletin (originally published in 2001), considered it appropriate to inform employers about the use of AEDs in the workplace.

Although Technical Bulletins are meant as advisory and informational, they are not meant to establish any independent legal obligations. Nonetheless, such recommendations often become and/or influence an implied standard of care.

The American Red Cross (ARC) has also been promoting the use of AEDs through its Health and Safety Services. Specifically, the ARC is not only advocating for professional and public access to AEDs, they provide the training for both professionals (EMTs and first responders, such as police and firefighters) as well as interested laypersons.

The ARC states that, "Training is necessary in order to understand the role of defibrillation in the broader context of the cardiac chain of survival. Training in CPR and AED skills will enable the rescuer to use all the steps in the cardiac chain of survival, thereby significantly increasing the victim's chance of survival."

Clearly, professional access is the standard of care for anyone whose responsibility includes responding to persons in cardiac arrest.

However, in recent years the American Heart Association has recommended "…more widespread use of AEDs by minimally trained laypersons."

The American Red Cross (ARC, 2004) describes further the concept of Public Access to Defibrillation (PAD):

"Public access to defibrillation is the term used for an initiative that makes AEDs available to the public by placing them in public and private places where large numbers of people gather. A PAD program includes all the steps necessary to get AEDs installed and people trained to use them [community assessment, education/promotion, funding, legislation, and implementation]. Local government employees, businesses, non-profit organizations, community organizations, schools and individuals can champion PAD programs. For more information about starting up your own PAD program, contact your local Red Cross."

The concept of public access does not necessarily mean that anyone witnessing a sudden cardiac arrest should be able to us an AED.

Rather, the scope of public access to defibrillation has AEDs used only by those with proper training and certification as governed by the Food and Drug Administration (FDA) and state regulatory agencies.

However, as recently as 2002, the FDA's Center for Devices and Radiological Health (CDRH) has suggested that "…training standards are governed by state and local laws rather than federal law. The FDA is reviewing whether AEDs should remain a prescription device and whether more extensive use of these devices should be permitted."

And, the American Heart Association is promoting "exploration of the use of bystander-initiated automatic external defibrillation in rural communities and congested urban areas where resuscitation strategies have had little success.

Other organizations with Position Statements on AEDs include (but are not limited to): the American College of Emergency Physicians, the American College of Occupational and Environmental Medicine, the American Public Health Association, the Citizen CPR Foundation, and the Emergency Care Research Institute.

A number of AED-related bills, being introduced at both the federal level and in state governments will likely increase the number of AEDs being purchased for use in public and private places.

Legislation like the Cardiac Arrest Survival Act (November 2000), and the more recently introduced Community Access to Emergency Defibrillation Act of 2001 have earmarked funds for installation of AEDs in federal buildings and supported the purchase and access to defibrillation programs in communities, respectively.

AEDs are becoming less expensive and easier to use with each generation of the product. Public organizations may be able to find public funds to support PADs and private organizations should consider the expense of a PAD as an excellent investment in risk management.

AED Quick-Reference
Issues to consider when deciding your AED policy:

1. Is it reasonable to have an AED available at each supervised program and facility within your camp?
2. If not, which facilities and programs should have an AED available?
3. Where AEDs are available, should they be accessible by only trained personnel, or by untrained personnel and bystanders as well?
4. Do you have consistent policies and procedures regarding AED usage?
5. Is your communication system quick enough to adequately respond in case of emergency, particularly if an AED is needed?
6. Does your signage clearly spell out what to do in case of an emergency?
7. What does your insurance/risk management company recommend?

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