MAJOR SOUTHEASTERN CITY: 11/12/2003 - A study that shows how well public access defibrillation (PAD) programs work also has produced startling findings about how they fail. The findings give researchers, program administrators and educators new areas to focus on as they try to save victims of sudden cardiac arrest.
Overall, the news is great: Twice as many lives were saved in public places that had automated external defibrillators, according to the National Institutes of Health PAD trial. But researchers say there are several areas where improvement is needed, particularly in designing strong volunteer response plans. "It's not the device; it's the quality of the program implemented," says Tom Aufderheide of the Medical College of Wisconsin in Milwaukee. "Programs require significant initial input, and they are very high maintenance."
Having a trained person on hand to use the automated external defibrillator (AED) - a computerized device that talks the rescuer through the three steps needed to save a life - is key when an emergency unfolds. When the heart needs a shock, time is crucial. Life and death is defined in six minutes.
One rescue from the pages of the study shows the cost of a delay. Volunteers at a gym had been trained to respond with the AED in the event of a cardiac arrest. Their plan: A call would be placed immediately to 911. Somebody would announce over the PA system that a defibrillator response was needed. The staffer at the front desk would grab the AED and rush to the victim's side. They practiced until they had the drill down perfectly. "We had three (practice cardiac arrests), and the time-to-shock was under two minutes all three times," Aufderheide says.
"But when a man suffered cardiac arrest on the squash court, the weaknesses in the response plan were instantly revealed. "On the day in question," Aufderheide says, "the person at the front desk had called in sick." Somebody called 911, and another person went on the public address system and asked "Is there a doctor in the building?" - which did not immediately signal the need for an AED. An AED trained volunteer went to the front desk and asked what the problem was. When told a man was down, the volunteer rushed to the victim's side - but without the AED. The staffer did the right thing - stayed and performed CPR and sent another person back to the front desk to get the defibrillator. That person "tells the temporary person who is working for the sick volunteer, 'I need an AED,'" Aufderheide says. "They look at them and say 'What's an AED?'" By the time the gym's device reached the victim, emergency crews had arrived. The man died.
Other problems are:
- Attrition. As many as half of the volunteers trained to respond left their jobs within a year.
- Security. The AEDs were hidden, and sometimes locked, away from the public in 55% of programs in a separate PAD study. Only 31% were accessible to the public.
- Retention. CPR skills fell to 87% proficiency when volunteers in the NIH study were tested a year after their initial training.
MAJOR SOUTHEASTERN CITY: 11/12/2003 - Access to defibrillators in public places and people who are trained to use them doubles the survival rate for victims of sudden cardiac arrest, says an ambitious new study.
A National Institutes of Health study of public access defibrillation - the most extensive clinical trial of its kind - shows that people with no other medical training can save lives by helping cardiac arrest victims before emergency medical services arrive.
Though the results are not surprising to many who have implemented these programs in such places as casinos and airports, they have be anticipated by experts seeking hard evidence. "We knew we could save more lives if we could get to people sooner, and we knew we could get there sooner if the defibrillator was on site and people knew how to use it," says Jerry Potts of the American Heart Association. "What we didn't have until now was a randomized study that proved it." The results were presented at the AHA's annual scientific meeting here.
In the study, nearly 20,000 people were trained to use defibrillators, computerized devices that even children can use to restart a heart. Volunteers were located in 993 public places in 24 areas of the USA and Canada. The sites were equally divided into those that had access to a defibrillator and those that did not, requiring volunteers there to use cardiopulmonary resuscitation. During the 21-month study, there were 232 cases of cardiac arrest and 44 survivors. Of the survivors, 29 had been treated with a defibrillator, 15 with CPR. CPR is vital, but when a heart is quivering in ventricular fibrillation, only a shock from a defibrillator will save the life, experts say.
In most cases, life and death is defined within six minutes. USA TODAY found this year that emergency medical systems in most big cities fail to reach victims in that time, costing more than 1,000 lives in the 50 largest US cities. Th USA TODAY report shows that of 250,000 Americans who die outside of hospitals from cardiac arrest each year, 56,000 to 76,000 suffer ventricular fibrillation - a treatable short circuit in the heart.
AEDs don't save lives... people do! An AED is a great tool, but like all tools, there are limitations.
- AEDs must be maintained and kept serviceable.
- AEDs must be readily accessible at all times.
- not located in a potentially unattended area
- not stored in a locked, inconspicuous, or unmarked location
- Effective protocols have to be developed, communicated, practiced, and kept up-to-date.
- The protocols must involve simple, explicitly defined, step-by-step procedures; remember, they are to be used in high stress, emergency situations.
- All staff and volunteers who work in the building should be trained in the protocols; not all need to administer an AED, but all should be able to initiate the protocol system.
- The procedures should be conspicuously posted or located in an easily seen, distinctly marked binder at the front desk.
- Any changes, e.g., location of the AED, means of activating 911, etc. must be immediately updated in the protocol and training.
- Although AEDs are easy to use, training is needed to use them quickly and competently in a stressful emergency situation. Remember, just six minutes can mean the difference between life and death.
- Training must be thorough and ongoing.
- Learning a skill involves more than mental comprehension... it requires hands-on practice.
- Mastering a skill demands more than an introduction... it requires repetition until it is done correctly, then more repetition until it becomes almost mechanical.
- Competency decreases significantly with time. However, properly timed and executed practice drills can actually improve competency, not just prevent its decline.
- Employee turnover adversely affects an association's readiness.
- A new employee may not be trained when the emergency occurs, and s/he almost certainly has less proficiency than an employee who has received ongoing training and drills.
- The more new staff, the more new training... new training is more time consuming, inconvenient, and costly than review.
- The study cites a turnover rate that might reach 50%...a great many YMCAs would be thrilled with such a number, as their turnover is even greater.
- Protocols should require that there are at least two staff members on site at all times who are currently trained in the administration of an AED.
- Don't forget CPR training...the article notes that in their study CPR skills had fallen to 87% proficiency after a year... our experience in auditing lifeguards has shown the average competency to be significantly below that level at the time of our first audit.
Please call us at 800-463-8546 to discuss this or any other risk management safety tip, or visit our web site at www.redwoodsgroup.com to learn more about YMCA risk management related issues.