Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015)

3

The Public Experience with Cardiac Arrest

As described in Chapter 1, the first three links in the chain of survival—early access, early cardiopulmonary resuscitation (CPR), and early defibrillation—are highly dependent on public engagement for a majority of cardiac arrest events. Under these circumstances, individuals may be required to provide basic life support, which includes mobilizing the delivery of emergency care (i.e., dialing 911), providing CPR, and using automated external defibrillators (AEDs), if they are available. Following a cardiac arrest and hospital discharge, family members and friends may be called on to provide support in continued care and rehabilitation for the individual recovering from the cardiac arrest.

Approximately 15 to 20 percent of EMS-treated out-of-hospital cardiac arrests (OHCAs) occur in a public place (Nichol et al., 2008; Vellano et al., 2015; Weisfeldt et al., 2010, 2011). The immediate, hands-on response of bystanders to cardiac arrest is critical to improve rates of effective resuscitation and, thereby, increase the likelihood of survival and positive neurologic outcomes for OHCA across the United States. For example, a definitive body of literature demonstrates statistically significant improvements to cardiac arrest survival rates when bystander CPR is performed (Akahane et al., 2013; Avalli et al., 2014; Campbell et al., 1997; Dowie et al., 2003; Ghose et al., 2010; Gilmore et al., 2006; Grmec et al., 2007; Herlitz et al., 2003, 2005; Kuisma et al., 2005; McNally et al., 2011; Nordberg et al., 2009; Rea et al., 2010a; Rudner et al., 2004; Vadeboncoeur et al., 2007; Vilke et al., 2005; Weiser et al., 2013; Yasunaga et al., 2010). By preventing the degradation of ventricular fibrillation (VF)—a shockable cardiac arrest rhythm—to a nonshockable cardiac arrest rhythm (as discussed in Chapter 1), CPR increases the number of patients who can be successfully resuscitated through defibril-

lation (Dowie et al., 2003; Gilmore et al., 2006; Nordberg et al., 2009). Bystander CPR is also associated with improved health outcomes for individuals who survive cardiac arrest. A number of studies have also found increased quality of life following cardiac arrest for individuals who receive bystander CPR compared to individuals who do not receive bystander CPR (Elliott et al., 2011; Granja et al., 2002; Mahapatra et al., 2005; Sladjana, 2011; Stiell et al., 2003; Yasunaga et al., 2010).

Various interventions and initiatives have been developed to increase public engagement in response to cardiac arrests. For example, placement of AEDs in public locations, implementation of effective emergency response plans in those locations, and use of AEDs in public locations have been shown to double a patient’s odds of survival from cardiac arrest (Aufderheide et al., 2006; Caffrey et al., 2002; Hallstrom et al., 2004; Hazinski et al., 2005; Kilaru et al., 2014b; Lick et al., 2011; Page et al., 2013; Valenzuela et al., 2000; White et al., 2005). Despite these efforts, many barriers prevent optimal public engagement in resuscitation efforts, which leads to disparate rates of bystander CPR and AED use and contributes to poor survival rates and health outcomes.

This chapter examines the role of the public in responding to witnessed cardiac arrests, including activation of the emergency medical services (EMS) system (see also Chapter 5), engagement in bystander CPR, and application of AEDs. In addition to reviewing existing literature about the effectiveness of the elements of basic life support, this chapter also explores barriers and opportunities for increasing public engagement in cardiac arrest response. These opportunities for engaging the public and improving survival from cardiac arrest include linking CPR and AED training to eligibility for high school graduation, supporting employer efforts to maintain AEDs and provide AED training to their employees, and strengthening current legal protections for trained and untrained lay rescuers who provide CPR and defibrillation via AED for OHCA patients.

BYSTANDER CPR

After recognizing a medical emergency, one of the first critical actions a bystander should take is to call 911, which mobilizes EMS responders to the scene. In the case of a cardiac arrest, blood suddenly stops circulating through the body and normal breathing ceases. Once the bystander confirms that the individual is no longer breathing normally,

CPR should be initiated and involves repeated chest compressions with or without rescue breathing under ideal circumstances. CPR provides oxygenated blood flow, keeping vital organs alive until the heart is able to resume pumping blood (Carpenter et al., 2003; White and Russell, 2002).

Bystander CPR makes the next link in the chain of survival, early defibrillation, more effective by increasing the proportion of individuals who are found with a shockable rhythm. In a study derived from the 1997 London Ambulance Service database that included 2,772 OHCAs, 48 percent of witnessed cardiac arrests with bystander CPR resulted in a ventricular tachycardia (VT) or VF rhythm; whereas, only 27 percent of witnessed arrests without bystander CPR were in VF/VT (Dowie et al., 2003). Among unwitnessed arrests, 31 percent of bystander CPR cases were in VF/VT compared to only 18 percent of non-bystander CPR cases (Dowie et al., 2003). Another study conducted by the Swedish Cardiac Arrest Register, which included 34,125 cases between 1992 and 2005, concluded that the provision of bystander CPR was associated with a higher likelihood of finding the individual in a shockable rhythm, and requiring fewer shocks to achieve return of spontaneous circulation (ROSC) (Nordberg et al., 2009). The relative benefit of bystander CPR also increases steadily when there are delays in the application of defibrillation and the collapse-to-defibrillation time increases. In a study of 2,193 VF arrests that occurred in a large metropolitan county between 1990 and 2004, the survival rate fell, and the association between survival and bystander CPR rose, as the collapse-to-defibrillation interval increased. Bystander CPR is especially important to the survival of patients who do not receive immediate defibrillation (Gilmore et al., 2006).

Despite the public’s generally positive opinion of CPR and evidence indicating the utility of bystander CPR, the rate of bystander CPR in the United States remains low at only 26 percent (Bagai et al., 2013; Coons and Guy, 2009; Johnston et al., 2003; Lester et al., 2000; Lynch and Einspruch, 2010; Urban et al., 2013). Understanding what evidence exists and what barriers must be overcome to increase bystander provision of CPR can help develop interventions and educational material that will support greater use of bystander CPR following cardiac arrest.

Effectiveness of Bystander CPR

Many national and international registry studies indicate that bystander CPR can increase survival rates for OHCA between 50 and 500

percent (Ghose et al., 2010; Gilmore et al., 2006; Grmec et al., 2007; Herlitz et al., 2003, 2005; Rudner et al., 2004; Vadeboncoeur et al., 2007; Vilke et al., 2005; Waalewijn et al., 2001; Wissenberg et al., 2013). Two recent studies using OHCA data from the Cardiac Arrest Registry to Enhance Survival (CARES) found that patients who received bystander CPR had a higher probability of survival than those patients who do not. For example, McNally and colleagues (2011) noted that of 31,689 OHCAs with presumed cardiac etiology, patients who received bystander CPR compared to those who did not had overall survival rates of 11.3 percent and 8.7 percent, respectively. Rea and colleagues (2010a) found a similar improvement in a sample of 10,681 OHCA patients, where survival rates were 22.1 percent in shockable cases where bystander CPR was performed compared to a 7.8 percent survival rate overall. A recent Swedish study also found that the positive correlation between early CPR and cardiac arrest survival rates remained stable over a 21-year period (Hasselqvist-Ax et al., 2015). A meta-analysis of 79 studies involving 142,740 patients found that OHCA victims who received bystander CPR had a fourfold increase in survival rates (16.1 percent) compared to those who had not (3.9 percent), and the number needed to treat to save one life ranged from 24 to 36 (Sasson et al., 2010b).

Bystander CPR alone can only explain a modest proportion of the variation in cardiac arrest outcomes, but there is evidence to suggest it represents an important modifiable determinant of survival with positive neurologic outcome. In an early study of 316 consecutive patients with VF arrest in Seattle between 1975 and 1976, neurologic outcome was better if resuscitation was attempted by a bystander prior to the arrival of EMS (Thompson et al., 1979). Two other, more recent studies of cardiac arrest patients in the United States demonstrated a trend toward improved neurologic outcome for OHCA victims who received bystander CPR compared to those who did not, but the results did not achieve statistical significance (Haukoos et al., 2010; Kaji et al., 2014). Additionally, data from the Resuscitation Outcomes Consortium (ROC) registry and CARES have found that the good Cerebral Performance Category (CPC) scores described in Chapter two are substantially higher among patients who presented with an initial cardiac rhythm of VF or VT compared to pulseless electrical activity or asystole (Daya et al., 2015; Vellano et al., 2015). Based on these statistics, it is inferred that promoting bystander CPR will lead to improved neurologic outcomes, by way of an increased

proportion of shockable first recorded rhythms among arresting patient (Kaji et al., 2014; Terman et al., 2014).

Stronger evidence to support the association between bystander CPR and improved neurologic function comes from several international studies. Among 95,072 bystander-witnessed cardiac arrests that occurred between 2005 and 2007 in Japan, bystander CPR increased the likelihood of favorable neurologic outcome (Yasunaga et al., 2010). In comparison with individuals who did not receive bystander CPR but did receive advanced cardiac life support (ACLS), the rates of survival with favorable neurologic outcomes were significantly higher when bystander CPR was combined with emergency medical technician ACLS and when bystander CPR was performed with physician ACLS. However, there were no significant differences in outcomes for individuals who did not receive bystander CPR but did receive physician ACLS (Yasunaga et al., 2010). The provision of bystander CPR also results in a significant improvement in both 1-month survival and favorable neurologic outcomes among pediatric patients (Akahane et al., 2013).

Moreover, provision of ACLS without bystander CPR substantially increases the number of patients who have unfavorable neurologic outcomes. Yasunaga and colleagues (2010) determined that the occurrence of vegetative status 1 month after a cardiac arrest was highest among patients who had received out-of-hospital ACLS performed by physicians but received no bystander CPR (Yasunaga et al., 2010). In another OHCA registry study from Italy, a lack of bystander CPR increased the odds of being discharged from the hospital with impaired neurologic outcomes (CPC score >2) (Avalli et al., 2014). In the Ontario Prehospital Advanced Life Support Study, the odds ratio (OR) for very good quality of life (Health Utilities Index Mark III >0.90) was 2.0 for patients who received bystander CPR compared to those who had not received bystander CPR (Stiell et al., 2003). This association between bystander CPR and good functional outcomes strongly reinforces the importance of promoting community CPR programs.

In addition to traditional CPR, which includes chest compressions and rescue breathing, there has been an increased interest in promoting the use of compression-only CPR (COCPR) in order to overcome bystander hesitation and concern with providing mouth-to-mouth rescue breathing (described later in this chapter). Minimizing interruptions in chest compressions has been associated with significant increases in survival. Even brief interruptions in chest compressions can negatively af-

fect circulation. Therefore, minimizing interruptions during bystander care may also be associated with improved outcomes.

Multiple studies comparing compression-only bystander CPR to traditional CPR with rescue breathing for adults with OHCA have found no significant differences in survival. In one multicenter, randomized trial of dispatcher-assisted bystander CPR, 1,941 eligible OHCA cases were randomized to receive chest compressions with or without ventilations. No significant difference in survival to discharge was found between the two groups (Rea et al., 2010b). There was also no marked difference in the proportion of individuals who survived with a favorable neurologic outcome (Rea et al., 2010b). Another randomized study demonstrated that 30-day survival rates were similar for COCPR and tradition CPR (Svensson et al., 2010). The Save Hearts in Arizona Registry and Education (SHARE) program noted increased survival rates (from 3.7 to 9.8 percent over 5 years) after implementation of a statewide effort focused on increasing bystander CPR rates by training lay persons on COCPR (Bobrow et al., 2010). Three major findings were identified by the SHARE program: (1) there was a significant increase in the rate of bystander CPR (from 28.2 to 39.9 percent); (2) COCPR increased during the study period (from 19.6 to 75.9 percent); and (3) as compared with conventional CPR, COCPR had a significant independent association with survival (Bobrow et al., 2010). Resuscitation councils now promote the use of COCPR for lay bystanders in efforts to increase the overall rate of bystander CPR. Despite the studies that demonstrate the effectiveness of COCPR for adults, there are circumstances in which traditional CPR is more effective than COCPR. For example, the addition of rescue breathing to compressions for asphyxia-precipitated cardiac arrests (e.g., trauma, drowning, acute respiratory diseases and apnea [e.g., with drug overdoses], airway blockage, and pediatric arrests) has been associated with increased rates of ROSC and 24-hour survival in animal models, as compared to COCPR (Berg, 2000; Berg et al., 1999; Sayre et al., 2008). For children who have OHCAs from noncardiac causes (e.g., asphyxiation), conventional CPR that includes rescue breathing was found to significantly improve survival with favorable neurologic outcomes over COCPR (7.2 percent versus 1.6 percent) and should be the preferred method (Kitamura et al., 2010b). However, COCPR is considered to have a survival benefit over no CPR at all.

Bystander CPR Rates: Community, Neighborhood, Socioeconomic, and Individual Considerations

There is wide variation in bystander CPR rates in the United States based on community, neighborhood, and socioeconomic factors. The magnitude of effect of bystander CPR is higher in communities that have lower baseline survival rates. In a meta-analysis, which included 79 studies involving 142,740 patients, the pooled odds ratio (OR) for survival among patients who received bystander CPR compared with those who did not ranged from 1.23 in the studies with the highest baseline survival rates to 5.01 in the studies with the lowest baseline rates (Sasson et al., 2010b). Variations in cardiac arrest outcomes are correlated with differences in bystander response rates. For example, a review of 28,289 OHCAs not witnessed by EMS personnel found that survival to hospital discharge was significantly higher among those who received bystander CPR (McNally et al., 2011). Another study of 4,821 OHCAs occurring in Hispanic and non-Hispanic white neighborhoods in Arizona found that bystander CPR rates were lower in the Hispanic neighborhoods, as were survival to hospital discharge rates (Moon et al., 2014). Among EMS systems that report data to CARES, wide variations of bystander CPR rates were noted from less than 10 percent to greater than 60 percent (McNally et al., 2011, Figure 6). This variation may have contributed to similar differences in corresponding overall cumulative survival rates—from less than 5 percent to greater than 20 percent (McNally et al., 2011).

Rates of bystander CPR also vary within individual communities. In a study of 161 census tracts within Fulton County, Georgia (including Atlanta), the frequency of bystander CPR varied from zero to 100 percent (Sasson et al., 2010a). Another study of 200 census tracts in Columbus, Ohio, found that although the rough average bystander CPR rate was 23.8 percent, the interquartile range was zero to 33.3 percent (Sasson et al., 2012b). Similar findings were reported in Franklin County, Ohio, where the average bystander CPR rate was 20.6 percent, yet rates of zero percent were found in several census tracts (Semple et al., 2013). Although the average prevalence rate of bystander CPR in Denver was determined to be 19 percent, it was as low as zero percent in some census tracts (Nassel et al., 2014).

Socioeconomic factors that influence bystander CPR rates can, in part, explain neighborhood variations. Multiple studies have demonstrated that low-income neighborhoods have markedly lower rates of bystander

CPR when compared with higher-income neighborhoods. In a study in King County, Washington, among cardiac arrests that occurred in a private residence, a higher socioeconomic status (SES) was associated with increased odds of the provision of bystander CPR (Mitchell et al., 2009). A similar correlation was found in Ottawa, Canada, where there was increased likelihood of bystander CPR with higher property values of the individual who experienced the cardiac arrest (Vaillancourt et al., 2008). Likewise, in Fulton County, Georgia, people with cardiac arrests that took place in census tracts within the highest income quintile, compared to the lowest income quintile, were much more likely (OR 4.98) to receive bystander CPR (Sasson et al., 2011). Reports from CARES demonstrate similar findings with bystander CPR rates increasing with median household income. Bystander CPR was used in 22 percent of cases with household incomes of less than $22,000 compared to 37 percent of cases with households with an income of greater than $64,000 (Sasson et al., 2012a).

Race and ethnicity are also associated with differences in bystander CPR rates. People who live in neighborhoods that include primarily Hispanic, African American, or poor populations are two to three times more likely to have OHCA (Warden et al., 2012). Additionally, multiple studies have shown that African Americans with an OHCA experience lower rates of bystander CPR compared to white individuals with an OHCA (Becker et al., 1993; Brookoff et al., 1994; Cowie et al., 1993; Shah et al., 2014). Likewise, Hispanic ethnicity of individuals with OHCA is also associated with lower rates of bystander CPR compared to non-Hispanic white individuals (Berdowski et al., 2009; Vadeboncoeur et al., 2008).

The interaction between race and ethnicity and bystander CPR is often a function of SES, with disparities most apparent when comparing bystander CPR rates in minority, poor, and non-English-speaking neighborhoods to high-income, white, English-speaking neighborhoods (Sasson et al., 2012b; 2013b). However, race and ethnicity are also independent predictors of bystander CPR. For example, bystander CPR rates are 19 percent less in high-income African American neighborhoods than rates in high-income non–African American neighborhoods (Sasson et al., 2012b). Moreover, Latino individuals, regardless of the neighborhood where the cardiac arrest occurs, are approximately 30 percent less likely than white individuals to receive bystander CPR (Sasson et al., 2012b; 2015).

Traditional CPR certification courses are poorly targeted at those most likely to be nearby when a cardiac arrest strikes, as the majority of participants are white and less than 50 years of age (Brennan and Braslow, 1998; Selby et al., 1982). Recognizing and understanding the relationships among community and neighborhood characteristics, SES, race and ethnicity, language barriers, and bystander CPR can help guide the design, implementation, and evaluation of CPR and public health interventions in an effort to increase bystander CPR use and improve health outcomes. Spatial epidemiological clustering techniques can be used to identify high-risk neighborhoods for OHCA incidence and low provision of bystander CPR in order to target and allocate resources for training where it is most needed.

Barriers to Bystander Response

Despite evidence that bystander CPR can improve health outcomes from cardiac arrest, each year less than 5 percent of the American public receives formal CPR training (Anderson et al., 2014). Provision of bystander CPR involves three critical steps: (1) the bystander must recognize the cardiac arrest and understand that the individual needs immediate EMS assistance, (2) the bystander must be willing to activate EMS by calling 911, and (3) the bystander must be familiar with and willing to provide CPR. Survey and focus group studies have identified multiple theories as to why bystanders do not engage in each of these crucial steps. Major themes can be divided into four categories, which are presented in rough order of importance:

1. An inability to recognize an OHCA followed by a delayed activation of EMS,
2. A lack of adequate CPR training,
3. Concerns about possible liability, and
4. Psychological factors, rescuer confusion, and health concerns.

Initiatives designed to increase bystander CPR must overcome existing barriers, respond to misconceptions, and teach the technical skills necessary to perform CPR with confidence. Efforts to improve the rate of bystander CPR will need to take the barriers discussed in this section into account if they are to be successful.

Recognizing Cardiac Arrest and Early EMS Activation

The first link in the chain of survival for OHCA is recognition and early activation of EMS. However, the bystanders may have difficulty recognizing the symptoms of cardiac arrest. A cardiac arrest, for example, sometimes can be mistaken for fainting or a seizure (Clawson et al., 2008). As described in Chapter 1, cardiac arrest may also be confused with a heart attack or other cardiovascular events, which may not require immediate response and treatment, as is the case with cardiac arrest.

In addition to mistaking the signs of cardiac arrest for other cardiopulmonary events or medical conditions, the actual symptoms of cardiac arrest can be confusing to bystanders. Individuals suffering from a cardiac arrest can continue breathing for several minutes after the arrest. However, the breathing is not normal. In a study of 100 tape recordings to emergency medical dispatches for cardiac arrest patients, the incidence of suspected agonal breathing (gasping) was estimated to be approximately 30 percent. Bystander descriptions of the breathing were reported as “difficult breathing,” “poor breathing,” “gasping,” “wheezing,” “impaired,” or “occasional breathing” (Bang et al., 2003). This agonal breathing is associated with survival, but decreases rapidly as time elapses (Bobrow et al., 2008). Importantly, agonal breathing can confuse bystanders, leading to miscommunication with dispatchers, and can delay the initiation of CPR (Berdowski et al., 2009). Another condition that can make recognizing cardiac arrest difficult is brief seizure-like activity (shaking) that occurs due to anoxic brain injury that results from the oxygen depletion that is associated with cardiac arrest (Clawson et al., 2008). These anoxic seizures can be confused with seizures that are more commonly associated with epilepsy and may further delay both bystander and dispatch action.

Bystanders may call a friend or relative before dialing 911, which can lead to delays in the identification of a cardiac arrest and early activation of EMS (Meischke et al., 2012). Barriers to early activation of 911 include distrust of law enforcement and fear of financial consequences. For many undocumented immigrants with limited English proficiency, language discordance and fear of exposing immigration status are significant concerns that may lead to delays in 911 activation (Ong et al., 2012; Sasson et al., 2013b; Seo et al., 2014; Skolarus et al., 2013; Watts et al., 2011). Understanding and overcoming these barriers can inform the development of culturally appropriate educational interventions to increase early recognition and improve outcomes.

The American College of Emergency Physicians (ACEP) supports the passage of laws that eliminate legal liability for good-faith reporting of emergencies related to drug overdoses (ACEP, 2014). Washington state amended its Good Samaritan law in 2010, and the response has been positive: 88 percent of surveyed drug users indicate that they would be more likely to call EMS in case of an overdose as a result of this amendment (Banta-Green et al., 2011). Protection from legal liability could be extended to include immigration status. So far 25 states have amended laws to encourage Good Samaritans to summon aid in the event of an overdose (Law, 2014).

Limited English proficiency in 911 callers is associated with delays in arrest recognition and implementation of telephone CPR (Bradley et al., 2011). Few studies have included data on bilingual language capabilities of dispatchers and preferred first language of limited-English-proficient callers. In one study of a call center where all call takers are monolingual speakers of English but translation services are available via an external company, requests formulated in English for a Spanish translator undermined the need for non-English and showed a low success rate in obtaining translation services (19 percent) compared to requests formulated in Spanish. Nonetheless, even the requests formulated in Spanish were successful in only 87 percent of cases (Raymond, 2014). Although public safety access points, such as 911, generally have translation services, the existence or availability of translation services is not synonymous with their accessibility or use. One way to overcome language barriers proposed in several cities and counties throughout the United States is to offer additional financial incentives for multilingual dispatchers (Jobs, 2015; Londoño, 2003; San Diego Police Department, 2015).

Lack of CPR Training

Fear of harming the unresponsive individual or performing CPR improperly are also commonly cited barriers. These concerns are frequently cited by individuals who have never received CPR training and those who have had training but fear that they have forgotten how to perform it correctly. Studies indicate that previous training increases bystanders’ confidence and willingness to perform bystander CPR (Cho et al., 2010; Coons and Guy, 2009; Donohoe et al., 2006; Johnston et al., 2003; Kuramoto et al., 2008). Similarly, CPR provision is more common in CPR-trained bystanders when CPR training has occurred within the past

5 years (Sipsma et al., 2011; Swor et al., 2006). Despite evidence that indicates the importance of bystander CPR in cardiac arrest outcomes (described previously in the report), an insufficient percentage of the public is trained in CPR. In a cross-sectional study of CPR training data from the American Heart Association (AHA), the American Red Cross, and the Health & Safety Institute, the median annual CPR training rate in all counties in the United States was 2.39 percent and varied widely across communities with median rates between 0.51 and 6.8 percent in the lower and upper tertiles (Anderson et al., 2014). Of counties located in southern U.S. states, those with higher proportions of rural areas with larger African American and Hispanic populations and those with lower median household incomes had lower rates of CPR training than other areas (Sasson et al., 2013b).

Training costs and time considerations are some factors that affect people’s decisions about seeking CPR training. Currently, CPR certification courses train a small fraction of the public in the United States—approximately 13 million annually out of 319 million (Anderson et al., 2014). Traditional CPR and AED certification courses may discourage would-be trainees because of time and money concerns (Roppolo et al., 2007). Traditional CPR certification takes approximately 4 hours to complete and requires a certified instructor in a classroom setting (AHA, 2011). While some of these courses are provided without charge through employers, many courses geared toward the general public require participants to pay a fee. Alternative models for delivering training to segments of the population who will not participate in classroom-based courses need to be expanded.

The cornerstone of traditional CPR training is through programs that integrate CPR training into civic, work, or school activities. Although some studies have suggested that certified instructor–led training may be superior, there is growing evidence to support alternative methods for bystander training (de Vries et al., 2010; Mancini et al., 2009; Yeung et al., 2011). Moreover, investigations of public CPR classes suggest that CPR certification courses are poorly targeted at those most likely to be nearby when a cardiac arrest strikes, because the majority of participants are younger than 50 years of age (Brennan and Braslow, 1998; Selby et al., 1982). Layperson instructors, computer and video self-instruction, and poster instruction provide similar competence at a lower cost as compared to traditional certification and have the potential to reach larger segments of the population (Castren et al., 2004; de Vries et al., 2008; Isbye et al., 2006; Meischke et al., 2001; Reder et al., 2006).

Previous trials have demonstrated that 30-minute training sessions, whether with video self-instruction or group training, can achieve equal or better post-training CPR knowledge compared to the traditional 4-hour-long AHA Heart Saver courses (Aldeen et al., 2013; Lynch et al., 2005; Todd et al., 1999). Moreover, home training by video self-instruction with peer facilitation has been shown to provide similar competence at a lower cost compared to traditional classroom-based training for lay responders expanding the reach of bystander CPR instruction (Wik et al., 1995). A more comprehensive description of alternative models for training to be used to enhance outreach, especially in traditionally disenfranchised communities can be found in the Alternative Training Strategies section in this chapter.

Concerns About Legal Liability

Good Samaritan laws are designed to protect those who choose to aid during an emergency, and are intended to reduce bystanders’ hesitation to assist. Although every state has a Good Samaritan law or act, the character of these laws varies from one jurisdiction to another. Some Good Samaritan laws apply to all citizen rescuers, while others are specifically written for physicians. In Pennsylvania, the law specifically protects lay rescuers who have CPR certification from the AHA or the American Red Cross. In Washington state, protection is provided for “any person providing emergency care,” regardless of prior training.¹ Good Samaritan laws in Minnesota and Vermont include language to establish and promote a minimum duty to provide reasonable assistance and alert medical personnel. These variations and complexities prevent potential bystanders from understanding the protections that these laws offer, thereby making them reluctant to act in an emergency (Law, 2014; Sasson et al., 2013a).²

A fear of legal consequences and a lack of familiarity with Good Samaritan laws are frequently cited as reasons for not performing bystander CPR (Coons and Guy, 2009; Sasson et al., 2013a). These fears are not without justification: although a bystander has no legal duty to rescue, there can be legal consequences for intervening (Hyman, 2005).

________________

¹Revised Code of Washington. 4.24.300. Immunity from liability for certain types of medical care.

²State-by-state descriptions of Good Samaritan laws are available online through multiple sources, including the Society for Human Resource Management (Society for Human Resource Management, 2015).

Theoretically, a member of the public could be sued for providing bystander CPR; however, the committee is unaware of any successful suit of this type. To mitigate the confusion and fear of potential rescuers, CPR instructors are urged to inform trainees of the protections available for lay rescuers in their area (Abella et al., 2008). Such instruction is especially important for individuals who are not fluent in English, because language barriers can exacerbate confusion about Good Samaritan laws (Sasson et al., 2013b).

Laws that do not adequately protect bystanders from legal action create disincentives for providing assistance and immediate action in emergency medical situations such as cardiac arrest (Banta-Green et al., 2011; Law, 2014). The limitations of current Good Samaritan laws have been recognized by the ACEP, which produced a 2014 policy statement calling for the widespread passage of laws eliminating legal liability for good-faith reporting of emergencies through 911 and other official communication channels, with the aim of encouraging bystanders to provide assistance during a potential drug overdose (ACEP, 2014). Similar policy statements calling for the protection of citizen rescuers who perform CPR along with financial support for public participation, education, funding, and coordination for successful implementation of such laws should be promoted by medical societies so as to eliminate this commonly cited barrier to performing bystander CPR.

Emotional Considerations, Mental Factors, and Health Concerns

Psychological barriers to performing CPR include panic, apprehension, and feelings of inadequacy in emergency settings. Women and nonnative English speakers, populations that report generally higher stress levels, cite these barriers more frequently than others. Panic may influence readiness to act in an emergency situation irrespective of prior CPR training (Sasson et al., 2013a). This may, in part, explain why individuals who have had a cardiac arrest are more likely to receive CPR if the arrest is witnessed by strangers as compared to friends or family members (Casper et al., 2003; Hyman, 2005).

Multiple studies report confusion, lack of knowledge about CPR, and fear of performing CPR incorrectly as major barriers to bystander CPR (Carruth et al., 2010; Reder et al., 2006; Sasson et al., 2013a; Taniguchi et al., 2007). In scientific statements, the AHA has acknowledged that the complexity of CPR potentially contributes to these barriers (Abella et al., 2008; Sayre et al., 2008). For example, guidelines call for ventila-

tions in all cases of pediatric cardiac arrest, regardless of the training of the rescuer (M. D. Berg et al., 2010; Biarent et al., 2010; Spencer et al., 2011). Compare this to adult cardiac arrest, where bystanders can provide either traditional or COCPR, while professional rescuers should provide traditional CPR in all cases (Hazinski, 2010). Although the shift to COCPR for lay rescuers is intended to simplify CPR, the existence of multiple guidelines may be a source of confusion for some bystanders. Moreover, frequent changes to the guidelines have themselves been cited as major sources of bystander confusion (Sasson et al., 2013a).

Resistance to providing rescue breathing, also known as mouth-to-mouth ventilation, is another noteworthy barrier for provision of bystander CPR (Locke et al., 1995; McCormack et al., 1989). One-fourth of people who suffer OHCA exhibit clinical signs of regurgitation at some point, and provision of rescue breathing increases the possible risk that the person will aspirate gastric contents (Virkkunen et al., 2006). Therefore, there are some legitimate medical concerns about use of rescue breathing following a cardiac arrest. However, bystander concerns typically revolve around the possibility of contracting a disease from the individual who has collapsed. Despite the paucity of documented cases of a communicable disease being transmitted to a rescuer following provision of rescue breathing, bystander reluctance is understandable and often cited as a large barrier to providing CPR (Locke et al., 1995; Ornato et al., 1990). The shift toward COCPR reduces concern for this commonly cited barrier and can increase the willingness of bystanders to perform CPR (Kanstad et al., 2011; Urban et al., 2013).

Strategies to Increase Bystander CPR Training

Although studies indicate that individuals who have previously participated in CPR training are more likely to initiate resuscitation than those who have not (Swor et al., 2006; Tanigawa et al., 2011), there are mixed results with regard to which types of training promote the highest-quality bystander CPR and longest retention of CPR skills and relevant knowledge. Since the initiation of bystander CPR training in the 1970s, efforts to increase bystander response have largely revolved around provision of traditional, certificate-based CPR courses that are employment, school, or event based, require several hours to complete, and can be costly. This approach has proven to be inefficient because CPR certification courses train only 3 percent of the public (Anderson et al., 2014). Moreover, such training approaches have proven to be especially

inefficient in reaching lay people in the southern United States, and in regions with higher proportions of rural areas and of black and Hispanic residents (Anderson et al., 2014). A more effective approach would reach all segments of the population regardless of SES, race, ethnicity, or geography and would target individuals who are most likely to be present when a cardiac arrest occurs.

School-Based Training

Educating the lay public in bystander CPR is clearly an important way to increase survival in OHCA. However, it is difficult to reach the entire population without mandatory programs. School-based interventions allow for a broad reach that encompasses all segments of the population, regardless of SES or race and ethnicity, and have potential to decrease disparities in the delivery of bystander CPR and use of AEDs. Because schools provide large-scale, centrally organized settings to which all children and their families have access, school-based interventions can be used to increase awareness, boost responses to cardiac arrest, and ultimately improve survival and cardiac arrest outcomes at the community level. Importantly, research suggests that CPR training in schools has support within minority communities (Sasson et al., 2014, 2015).

One benefit of incorporating CPR and AED training during the school year is that students are already primed for learning. Studies comparing CPR training for children with similar training for adults indicate that children can score better than adults on multiple-choice questionnaires when similar CPR training methods are used (Jimenez-Fabrega et al., 2009; Rosafio et al., 2001). Furthermore, schools provide a platform for repeated training opportunities, and repeated training has been associated with better retention of resuscitation skills. Studies looking at retention between 3 to 12 months after training demonstrate an expected improvement in knowledge and skills after training, which is then followed by a deterioration of skills following the initial training (Christenson et al., 2007; Woollard et al., 2006). The optimal frequency of refresher training is unknown, but annual training compared to biannual training does not appear to provide a remarkable advantage (Bohn et al., 2012).

The widespread adoption of school-based CPR and AED training would not be expected to substantially increase bystander CPR rates throughout the country. In the near time, the training would provide a valuable skill set that could increase the likelihood for an appropriate

response to an emergency throughout that student’s lifetime. Moreover, school programs that promote taking CPR and AED study materials home to share with family members could multiply the number of adults trained in CPR and AED use, because students could share their new knowledge and skills with adult family members and other community members who may be more likely to witness a cardiac arrest (Isbye et al., 2007a,b; Lorem et al., 2008, 2010). For example, one study of high school students found that each high school student who took an educational manikin-DVD set home ended up training, on average, an additional 2.8 adults to perform CPR with 43 percent of newly trained adults being over the age of 50 (Lorem et al., 2010).

Training in schools is an essential component of a comprehensive approach to improve OHCA survival and outcomes across communities. In the long term, CPR and AED education in schools represents an investment in training multiple generations of people, and it could greatly multiply the number of adults willing to perform bystander CPR and use an AED in one generation. Although there are no longitudinal studies that assess the impact of school-based CPR training on the probability that students will provide CPR as adults, evidence demonstrates that training—undertaken at any point—increases the likelihood that a bystander will provide appropriate care when faced with an OHCA (Swor et al., 2006; Tanigawa et al., 2011). Moreover, the success of communities in Denmark, Minnesota, and Norway, where improved OHCA outcomes have been observed with increased rates of bystander CPR, has been attributed in part to school-based CPR and AED training (Lick et al., 2011; Lindner et al., 2011; Wissenberg et al., 2013). Reliably increasing the percentage of community members who are trained in CPR and AED use through school-based programs is an effective component to improve the overall community response to cardiac arrest, thereby reducing time to first compression.

The use of school-based CPR and AED training programs has been endorsed by the World Health Organization in a joint statement titled “Kids Save Lives,” which is also supported by the European Patient Safety Foundation, the European Resuscitation Council, the International Liaison Committee on Resuscitation (ILCOR), and the World Federation of Societies of Anaesthesiologists (Böttiger and Van Aken, 2015). The joint statement recommends that school children received resuscitation training every year beginning at the age of 12 years (Böttiger and Van Aken, 2015). CPR and AED training in schools has also been endorsed by the AHA, the American Academy of Pediatrics, the American College

of Emergency Physicians, the National Association of School Nurses, and the Society of State Directors of Health, Physical Education, and Recreation (Cave et al., 2011). Some schools have also been supportive of CPR training for students (Reder and Quan, 2003). Communities across the United States are recognizing the value of including resuscitation training in school curricula. Currently, there are 20 states that have mandated CPR education as a condition for graduation for high school students (AHA, 2015a) (see Appendix E).³ Despite existing mandates, the specific recommendations for training vary from one state to another, and most states have not designated additional funds to support the training nor have they specified the age at which the mandated training should occur.

Lack of funds and limited class time for CPR and AED training remain two of the largest barriers to incorporating CPR training in schools (Reder and Quan, 2003). In an effort to ease financial constraints, a bill that was designed to establish and provide grants to facilitate CPR and AED training in public elementary and secondary schools was introduced in the U.S. House of Representatives in 2013.⁴ However, the bill was never enacted. Some states, such as Colorado and North Dakota, have established programs that reimburse the purchase of CPR and AED training equipment for schools.⁵ Although legislation in Massachusetts does not mandate, but rather encourages, CPR training in schools, the state offers funding for training programs when they are included as part of a health education program.⁶

A number of options aimed at overcoming financial obstacles and time constraints for training in schools have been introduced and supported in the academic literature. Shorter CPR training courses can address concerns about the limited ability of some students to attend long classes. Highly condensed CPR training can be effective at developing competency in CPR among students (Jones et al., 2007; Meissner et al., 2012). In basic life support (BLS) courses as short as 60 minutes long, middle school students can develop proficiency in COCPR and AED use (Kelley et al., 2006). Furthermore, the use of non–health care instructors, such as schoolteachers (Bohn et al., 2012; Toner et al., 2007), medical

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³Two more states (Oregon and West Virginia) will begin requiring CPR certification for high school graduation in 2015-2016.

⁴Teaching Children to Save Lives Act of 2013, H.R. 2308, 113^th Congress, 1st sess. (2013-2014).

⁵Colorado House Bill 14-1276 and North Dakota Senate Bill 2238.

⁶Massachusetts Law, Part 1, Title XII, Chapter 71, Section 1, 2015.

students, and peer tutors may reduce cost and scheduling difficulties associated with CPR courses (Breckwoldt et al., 2007; Carruth et al., 2010; Plant and Taylor, 2013). Training schoolteachers to be CPR instructors should be viewed as a long-term investment enabling teachers to train successive classes of students and incorporate CPR training into lesson plans for required courses, such as health or physical education. Another option is to move learning out of the school and into the home by giving self-instruction kits or assigning computer-based training programs as homework (Isbye et al., 2007b; Reder et al., 2006).

CPR as a Prerequisite to Other Activities

Half of the countries in the European Union have mandatory first aid and CPR training requirements in place in order to obtain a driver’s license (Adelborg et al., 2011). Many of these mandates exist in conjunction with other national initiatives, such as school trainings and public awareness campaigns. These factors have contributed to the increase in bystander CPR rates in countries such as Denmark and Sweden (Stromsoe et al., 2010). Although there is no mandatory requirement for CPR training in the United States, the idea has been introduced in Ohio and Connecticut without success. Ohio’s House Bill 283, which was introduced in 2011, would have required instruction in CPR and AED use as a graduation requirement.⁷ Ohio House Bill 580, introduced in 2014, would have mandated that teenagers younger than 18 submit proof of completion of a first-aid and CPR course within 1 year after applying for a driver’s license.⁸ Connecticut’s House Bill 6054, which was introduced in 2013, would have prohibited the commissioner of the state Department of Motor Vehicles from issuing or renewing a driver’s license if an applicant had not received a CPR certification (Gendreau, 2013).

Laws regulating employer-based CPR and AED training are determined, in part, by state-level public access defibrillation (PAD) regulations and federal-level Occupational Safety and Health Administration regulations. Federal Aviation Administration regulations require that flight attendants receive instruction in proper CPR techniques and AED use that includes the performance drills followed by refresher training and drills at least once every 24 months (FAA, 2006). Likewise, the Healthcare Research and Quality Act of 1999 and the Public Health Service Act require the U.S. Department of Health and Human Services to

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⁷Ohio House Bill 283, 129th General Assembly, 2011-2012.

⁸Ohio House Bill 580, 130th General Assembly, 2013-2014.

produce a set of guidelines for CPR and AED training in federal government facilities. The law states that, “in facilities where there are sufficient numbers of personnel to permit in-house training programs, a routine training schedule should be established”; that “formal refresher training should be conducted at least every 2 years”; and that “it is recommended that lay rescuer/responder teams engage in periodic ‘scenario’ practice sessions to maintain their skills and rehearse protocols” (GSA, 2001).

Preparing Family Members to Respond to Cardiac Arrest

Given that four out of five cardiac arrests occur in at home, the people most likely to be on hand to provide immediate response to CPR are family members (AHA, 2015b; Swor et al., 2003; Waalewijn et al., 2001). Members of the public who are exposed to educational materials promoting CPR, or who believe CPR should be performed prior to EMS arrival, express greater intention to, respectively, train in or perform CPR (Vaillancourt et al., 2013). The hospital setting may be an effective training location for family members of patients who are recovering from myocardial infarction, a particularly high-risk group for subsequent cardiac arrest. Emergency departments also provide an opportunity to refer high-risk patients and their families for appropriate CPR training. In a cross-sectional study of patients presenting to the emergency department with chest pain, only two in five households had prior CPR training. Yet, two out of every three households were willing to participate in CPR classes (Chu et al., 2003).

CPR training can reduce anxiety and help empower family members, friends, and caregivers of high-risk patients. One study of parents with high-risk children (i.e., those with premature birth, congenital heart defects, and history of apnea) demonstrated that the use of a take-home educational manikin-DVD set can provide sustained knowledge and confidence (Knight et al., 2013). The intent of the educational manikin-DVD set is to allow individuals to use the kits at home or in the workplace for self-instruction at a convenient time. When shared with others, the kits expand the number of trained individuals to include other family members, friends, and colleagues (Potts and Lynch, 2006). The kits were originally developed by the AHA and Laerdal Medical AS (Stavanger, Norway) and contain a small manikin and a 22-minute training video. The manikin allows individuals to practice the psychomotor skills of

CPR, but it does not provide similar simulation for AED application of pads and administration of a shock.

In another study of parents with premature infants and children with congenital heart disease, the use of a video self-instruction training kit for infant CPR increased caregiver comfort and led to training for a total 3.1 persons per kit, which was the result of parents sharing the kit with other caregivers (Pierick et al., 2012). In a study of adult family members or friends of patients who were admitted to a hospital with cardiac-related diagnoses, CPR training promoted self-confidence and increased secondary training of family members who were not captured by hospital training opportunities (Blewer et al., 2011). To improve cardiac arrest survival rates, especially for cardiac arrests that occur in homes and other private settings, policy makers and health care systems need to consider the widespread implementation of training for family members of patients who have medical conditions that place them at higher risk for cardiac arrest. These training programs could be included as part of hospital discharge instructions for parents of high-risk children, family members of survivors of myocardial infarction, and patients with other cardiovascular risk factors.

Critical Teaching Points for Bystanders

Any program designed to teach lay bystanders how to respond to an OHCA must include instruction on the first three links of the chain of survival: early recognition and activation of the emergency response system, CPR, and AED use. Studies have demonstrated that delays in bystander response to emergency situations may be due to uncertainty or any of the barriers described above. Nonresponding bystanders sometimes vacillate between two undesirable alternatives: acting when there is no emergency and not acting when there is an emergency. Because the signs and symptoms of a cardiac arrest can be confusing, early recognition is the most critical step. Some organizations who offer CPR training courses have simplified criteria for starting CPR. Training courses may no longer instruct bystanders to search for a pulse or watch and feel for breathing. Instead, bystanders are encouraged to start CPR on any person who has collapsed, is unresponsive as assessed by tapping and shouting, and has abnormal or absent breathing (R. A. Berg et al., 2010). It is unknown whether brief training modalities provide adequate instruction on cardiac arrest recognition compared to traditional instructor-led courses, because this component has not been tested in prior studies.

Studies have indicated that cardiac arrest outcomes are directly related to the quality of CPR provided, which includes chest compression depth, chest compression rate, and the duration of interruptions to compressions (Cheskes et al., 2014; Idris et al., 2015; Kramer-Johansen et al., 2006; Stiell et al., 2014). Achieving the target compression depth in adult victims of cardiac arrest requires the application of considerable force, and is difficult to achieve for children younger than 13 years old given their size and physical limitations (Aelen et al., 2013; Tomlinson et al., 2007). Therefore, it is reasonable to introduce instruction of adult CPR chest compression skills in middle school and not sooner. However, children as young as 4 or 5 years can be trained in the steps of cardiac arrest response, including recognition, activation of EMS by dialing 911, and opening the airway of a victim (Bollig et al., 2011). Moreover, the quality of bystander CPR is associated with a higher probability of survival than having no CPR. For this reason, inability to achieve chest compression depth or rate should not dissuade would-be rescuers from performing CPR.

Alternative Training Strategies

As noted previously, the necessary time and money for traditional classroom CPR and AED training certification may discourage the public from participating in these courses and obtaining requisite skills. Investigations of public CPR classes also suggest that CPR certification courses do not reach the individuals who are most likely to be present when a cardiac arrest occurs, with the majority of participants being younger than the populations that most commonly suffer from—and are witnesses to—cardiac arrest (Brennan and Braslow, 1998; Kramer-Johansen et al., 2006). Although some studies have suggested that certified instructor–led CPR training may be superior to other training approaches (de Vries et al., 2010; Mancini et al., 2009), there is growing evidence to support alternative methods for bystander training (Yeung et al., 2011). Layperson instructors (Castren et al., 2004) and computer and video self-instruction with practical skills modules (Isbye et al., 2006; Meischke et al., 2001; Reder et al., 2006) provide similar competence in CPR at a lower cost compared to traditional certification and have the potential to reach larger, more diverse segments of the population. For AEDs, self-training with a poster, a manikin, or a training AED were shown to be equally effective at maintaining competency in AED usage among students already trained in BLS (de Vries et al., 2008).

Randomized controlled trials have demonstrated that a 30-minute training module, whether provided through video self-instruction or group training, can achieve comparable or better post-training CPR knowledge and performance when compared to the traditional 4-hour AHA Heart Saver courses (Aldeen et al., 2013; Lynch et al., 2005; Todd et al., 1999; Wik et al., 1995). Home training by video self-instruction with peer facilitation has also been shown to provide similar competence at a lower cost in comparison to traditional classroom-based training. This approach can also be used to expand the reach of bystander CPR instruction (Wik et al., 1995).

Even ultrabrief, COCPR video training can teach adult bystanders basic CPR skills in just 60 seconds. These types of modules have demonstrated improved responsiveness, chest compression rate, and increased proportion of total resuscitation time spent providing chest compressions (Panchal et al., 2014). Similarly, cell phone apps for self-directed CPR training with feedback mechanisms can improve chest compression performance in simulated cardiac arrest scenarios. This new approach to training promises a boost in knowledge and confidence in CPR performance over a short period of time (Merchant et al., 2010; Semeraro et al., 2011).

Dispatcher-Assisted Training

Dispatcher-assisted training via telephone instruction, which is discussed in greater detail in Chapter 4, has demonstrated an increase in bystander CPR rates (Rea et al., 2001; Stipulante et al., 2014). Early simulation studies proposed the use of dispatcher-assisted CPR as a strategy to increase the rate of bystander CPR in communities where few people have CPR training and to improve the quality of CPR performed by bystanders who had prior training (Kellermann et al., 1989). Clinical studies have confirmed the success of this approach. One study of 7,265 EMS-attended, adult cardiac arrests between 1983 and 2000 in King County, Washington, determined a multivariate adjusted OR of survival of 1.69 for dispatcher-assisted bystander CPR compared with 1.45 for bystander CPR without dispatcher assistance (Rea et al., 2001). Another study conducted in Belgium concluded that bystander CPR increased from 9.9 to 22.5 percent after the implementation of a dispatch protocol that included CPR instructions (Stipulante et al., 2014).

Although dispatcher-assisted CPR has great potential to increase bystander CPR rates, challenges remain in populations with limited English

proficiency. Non-English-speaking bystanders may have difficulty in accurately relaying information to dispatchers and then receiving instructions that are understandable to them. One study noted that it took dispatchers longer to recognize cardiac arrest when talking to callers who had limited English proficiency compared with callers who were fluent in English. The interval from call receipt to initiation of CPR was also longer for callers with limited English proficiency compared with callers who were fluent in English (Bradley and Rea, 2011). A higher level of English proficiency and a greater proportion of time spent in the United States were strong predictors of CPR training and intention to call 911 in an emergency (Meischke et al., 2012). These factors highlight the importance of focusing efforts on reaching out to and training most communities that have lower levels of English proficiency.

Models of Success: The Power of Multiple Initiatives

Denmark recognized the low frequency of bystander CPR (less than 20 percent) and low 30-day survival from cardiac arrest (less than 6 percent) and took steps by adopting several national initiatives to strengthen bystander resuscitation attempts. These initiative included (1) the implementation of mandatory resuscitation training in elementary schools, as well as when acquiring a driver’s license, (2) an initiative to increase voluntary first-aid training, (3) free distribution of CPR self-instruction training kits, (4) nationwide improvement efforts in delivering dispatch-assisted CPR instruction, and (5) an increase in the number of AEDs placed in public locations. These national initiatives, combined with improved EMS performance and post–cardiac arrest survival rates, have led to an increase in the 1-year survival rates for cardiac arrest patients from 2.9 to 10.2 percent over the span of a 9-year period (Wissenberg et al., 2013).

Another similarly successful model of community-based initiatives to improve cardiac arrest survival rates is Minnesota’s Take Heart America program. This initiative included widespread CPR and AED training in schools and businesses, deployment of AED in schools and public places, and updates to EMS and post–cardiac arrest care protocols. This initiative was correlated with an increase in bystander CPR rates between 2005 and 2009 from 20 to 29 percent. An increase in survival to hospital discharge for all patients following an OHCA from 8.5 to 19 percent was also documented (Lick et al., 2011). Arizona’s SHARE program was the first to train lay persons in COCPR. SHARE is responsible for training

more than 100,000 people using a range of methods that includes classes, video viewing, and other marketing methods such as a brief online training video. In association with this program, bystander CPR rates in Arizona have increased from 28 percent in 2005 to 40 percent in 2009 (Bobrow et al., 2010).

PUBLIC ACCESS DEFIBRILLATION (PAD) PROGRAMS

Cardiac arrests caused by shockable arrhythmias (e.g., VF, VT) are typically treated by the application of an electrical shock that is delivered by an AED, as discussed in Chapter 1. Studies indicate that most cardiac arrests that occur in public are due to VF (Nichol et al., 2008; Weisfeldt et al., 2010, 2011). While CPR can extend the window for successful defibrillation for cardiac arrest caused by VF, it is only defibrillation that can reverse VF. When CPR and AEDs are used very early for individuals with VF, survival rates are excellent—usually between 40 and 75 percent (Caffrey et al., 2002; Valenzuela et al., 2000; Weisfeldt et al., 1995a,b, 2010). Despite the significant benefit of AEDs, they are rarely immediately available or used by bystanders. In the ROC registry, which includes 11 sites in the United States and Canada, AED use by bystanders occurred in only 2.1 percent of all cardiac arrests (Daya et al., 2015; Weisfeldt et al., 2010). CARES, which includes 55 communities in 23 states, found that AED use occurred in approximately 4 percent of all cases (Vellano et al., 2015).

Although rare, cardiac arrest in children and adolescents is associated with extremely poor survival rates, ranging from 3 to 12 percent. Ventricular arrhythmias account for 4.9 to 19 percent of OHCAs in children and adolescents (Atkins et al., 2009; Daya et al., 2015; Donoghue et al., 2005; Mogayzel et al., 1995). As with adults, outcomes for children with VF-related cardiac arrest are better than for those with other cardiac arrest rhythms. VF-specific algorithms for defibrillation that were originally developed for adult populations also have been shown effective when applied to pediatric populations (Hickey et al., 1995; Mogayzel et al., 1995). It remains unclear how AED algorithms perform for other rhythms like supraventricular tachycardia and VT in pediatric patients (Rustwick and Atkins, 2014). However, the AHA does recommend the use of AEDs in children older than 1 year (Samson et al., 2003).

Considering the demonstrated effectiveness of early defibrillation, the opportunity to improve access to AEDs for bystanders and first re-

sponders led to the establishment of PAD programs across the United States (Hazinski et al., 2005). PAD programs, also known as lay rescuer AED programs, are intended to improve OHCA by increasing the likelihood that a bystander can access, apply an AED, and provide potentially lifesaving early defibrillation when needed. Several studies have aimed to identify public locations and buildings where cardiac arrests are most likely to occur (Becker et al., 1998; Engdahl and Herlitz, 2005; Fedoruk et al., 2002; Folke et al., 2009). Recommendations have been developed that describe the placement of AEDs in public locations based on specific criteria, which include any combination of the following:

• More than 250 adults over the age of 50 accessing the location more than 16 hours per day,
• The presence of high-risk individuals or a high-risk location,
• Health Clubs with more than 2,500 members, and
• A cardiac arrest event at the location at least once every few years (Aufderheide et al., 2006; Becker et al., 1998; Handley et al., 2005).

Further work on determining the optimal locations for strategically placing AEDs could help with evaluating these recommendations and developing guidelines for locations adopting PAD.

Effectiveness of PAD Programs

To date, many PAD programs have been implemented worldwide and have demonstrated improved cardiac arrest outcomes (Berdowski et al., 2011; Bertrand et al., 2004; Hallstrom et al., 2004; Hansen et al., 2013a; Kitamura et al., 2010a; Lick et al., 2011; Sasson et al., 2013b). Statistically significant improvements in rates of survival with favorable neurologic outcome have been shown in federal buildings (Kilaru et al., 2014b), airports (Caffrey et al., 2002), casinos (Valenzuela et al., 2000), fitness centers (Page et al., 2013), churches, schools, workplace environments, and other locations that have implemented a PAD program. The survival rates for locations with PAD programs can vary between 28 and 56 percent (Berger, 2014).

General PAD Programs

A 2002 study that evaluated the effectiveness of AED installation in heavily trafficked public locations found that 10 out of 18 individuals who collapsed with a VF-related cardiac arrest over a 2-year period in Chicago’s O’Hare Airport were successfully resuscitated and survived with excellent neurologic outcomes a year after the arrest (Caffrey et al., 2002). In 2004, the PAD Trial, which involved trained laypersons in 24 North American regions, found a statistically significant twofold survival benefit with favorable neurologic outcome for adults who received bystander CPR plus AED compared with those who only received bystander CPR (Hallstrom et al., 2004). Data from the ROC database, which was published in 2007, showed that OHCA patients had significantly better outcomes when the first shock was applied by a bystander before EMS arrival (Weisfeldt et al., 2007). Additionally, multiple observational studies all demonstrated statistically significant improvements in odds of survival when an effective PAD program was in place (Berdowski et al., 2011; Cappato et al., 2006; Capucci et al., 2002; Culley et al., 2004; Fleischhackl et al., 2008; Iwami et al., 2012; Kitamura et al., 2010a; Kuisma et al., 2003; Mitani et al., 2013; Rea et al., 2010c; Swor et al., 2013; Weisfeldt et al., 2011, 2010). The timely use of AEDs by bystanders has been consistently and repeatedly deemed effective, making AED use one of the most definitively beneficial interventions known for cardiac arrest caused by a shockable rhythm.

The availability of AEDs through PAD program can substantially reduce the time to defibrillation in the United States where EMS response averages 9.4 and 9.2 minutes from dispatch to arrival on scene for adult and pediatric patients (NEMSIS, 2012). Survival rates for witnessed VF with and without bystander CPR decrease by 3 to 4 percent and 7 to 10 percent, respectively, with every minute that passes between collapse and defibrillation (Larsen et al., 1993; Valenzuela et al., 1997). Notably, the audible CPR instructions programmed into AEDs can provide life-sustaining support until EMS arrives even for individuals with nonshockable rhythms (Chiang et al., 2005; Williamson et al., 2005). However, to be successful, PAD programs must reduce the time to defibrillation prior to EMS arrival. Strengthening and expanding PAD programs could offer opportunities to fortify a scientifically proven and vital component of the public response to cardiac arrest.

In order to maximize utility and the likelihood of an AED being used by a bystander to provide lifesaving support, dissemination of AEDs

should be coordinated so that the AEDs are strategically located in high-risk public places where cardiac arrest is most likely to occur. Data from an uncoordinated AED placement program in Copenhagen, Denmark, indicated that despite a 15-fold increase in AED coverage over 4 years (2007-2011), 94.6 percent of all AEDs were placed in low-risk areas or places without any cardiac arrests. However, the study reaffirmed the association between very early AED defibrillation and survival, demonstrating that 30-day survival for cases of bystander AED application was 87.5 percent compared to only 19.2 percent when bystander AEDs were not used (Hansen et al., 2014).

PAD programs have been shown to be cost-effective in different settings with the cost per quality-adjusted life-year (QALY) ranging from $30,000 to $100,000, which is within the acceptable range for many medical therapies (Berger et al., 2004; Cram et al., 2003; Foutz and Sayre, 2000; Nichol et al., 1998). Other studies have found that the cost per QALY can be higher (e.g., $108,700 per QALY), reducing the cost-effectiveness, when AEDs are placed in programs without a strategically informed focus that includes adequate training, maintenance, and EMS integration (Folke et al., 2009). These cost per QALY estimates are highly dependent on the inputs and assumptions made in developing the cost-effectiveness analysis models and can vary based on the costs associated with program development, maintenance, training, and patient outcomes.

Reported experiences with PAD programs and first-responder programs over the past two decades have identified specific elements that are required in order to achieve success (Hazinski et al., 2005). These elements extend beyond just installing AEDs in public locations and expecting bystanders to use them. Other elements for success include the overall organization of a PAD program, establishing a functional and practiced internal emergency response plan, offering adequate training for CPR and AED use, and integrating the program with local EMS systems (Foutz and Sayre, 2000). In this context, emergency response planning that includes all of these elements is important for realizing the full potential of PAD programs to improve OHCA outcomes.

Other countries have demonstrated the potential for bolstering PAD programs by implementing nationwide initiatives that are focused on increasing bystander CPR and AED use overall (Wissenberg et al., 2013). For example, between 2001 and 2010, Denmark implemented strategies that were designed to strengthen or initiate PAD programs. National efforts included a multifaceted approach to increasing resuscitation training (e.g., in schools, before obtaining a driver’s license, and distribution of

free CPR training kits), an increase in the number of publicly accessible AEDs, and the implementation of EMS dispatch instructions regarding the nearest AED (Wissenberg et al., 2013). During the study time frame, bystander use of AEDs was low (1.1 to 2.2 percent); however, when AEDs were used, there was a significant increase in survival rates (Wissenberg et al., 2013). Factors attributed to low AED use included the fact that expanded placement of public AEDs only happened near the end of the study and only one-quarter of OHCAs occurred in public locations where AEDs were located.

Data from the Amsterdam Resuscitation Study (ARREST) of North Holland indicated that when the location of publicly available AEDs was promoted (although not controlled or directed), the use of these AEDs increased almost threefold, from 21.4 to 59.3 percent, during the 6-year study period (2006-2012). The study also found that survival to hospital discharge with favorable neurologic outcome for patients with shockable rhythms also increased during the study period. These findings were attributed to a constellation of interventions that included equipping police teams with AEDs, a public campaign to increase AED knowledge and awareness, and encouraging a less than 6-minute window for the time between the 911 call and the shock (Blom et al., 2014). The ARREST work has also been expanded to include alerting volunteers via mobile phone of an OHCA event and nearby AEDs (Zijlstra et al., 2014). Data from ARREST have specifically illustrated how a text messaging system that activates local responders can increase early defibrillation for OHCA (Zijlstra et al., 2014).

The studies described throughout this section support the efficacy of PAD programs and the bystander use of AEDs. As described here and throughout this chapter, the best strategy for improving survival and outcomes through bystander CPR and AED use is to develop and implement multipronged initiatives that not only teach the skills necessary to respond, but also instill a culture of action throughout communities and the public.

Children and School-Based PAD Programs

In recent years, particular attention has been focused on AED placement and education in school settings (Berger et al., 2004; Cave et al., 2011; Drezner et al., 2009; Hart et al., 2013). As with CPR training, schools provide a valuable opportunity for widespread AED training across a large segment of the populations. School attendance in the United

States approaches 98 percent for elementary and middle school students and is similarly high (97.1 percent) for students aged 14 to 17, but lower (71.1 percent) for students aged 18 to 19 (U.S. Department of Education, 2012). Students represent an important audience for educational and training efforts related to cardiac arrest and AED use. As described previously with CPR, training school-children about AEDs could also lead to more adults learning about defibrillation (Chamberlain and Hazinski, 2003).

The AHA specifically recommends that AED training and skills practice should be included in CPR training that occurs in school settings (Cave et al., 2011). Studies of untrained third-grade students have been shown that they are able to effectively use AEDs, and sixth-grade students have demonstrated AED competence similar to EMS providers (Gundry et al., 1999; Lawson and March, 2002). Courses can successfully employ multiple training modalities, and among high school students, AED skills are retained for as long as 6 months after training (Fernandes et al., 2014; Plant and Taylor, 2013). For AEDs, cognitive skills are the primary focus for training, because the only required psychomotor skill is the ability to turn on the device and place the defibrillation pads. Furthermore, easy-to-understand visual and audible instructions are integrated into the AED devices and are provided as soon as the device is turned on, making operation simple and straightforward for most users.

School PAD programs have been shown to contribute to improved outcomes after cardiac arrest in school teachers and students (Cave et al., 2011; Drezner et al., 2009; Kovach and Berger, 2012; Swor et al., 2013). Despite differences in training and compliance and variability in willingness to respond in school settings, when resuscitation efforts occur, high rates of bystander CPR (up to 94 percent), shock with an AED (upward of 83 percent), and survival to hospital discharge (upward of 64 percent) have been reported in school settings (Drezner et al., 2009). A study from Japan also showed that AED use in schools for bystander-witnessed OHCA is increasing over time and can occur with a shortened collapse to shock by public-access AED time (Murakami et al., 2014). Importantly, schools with at least one AED on campus are more likely to implement other readiness measures, including development of an emergency action plan, establishing a system for activating the emergency response system, and ensuring early access to defibrillation (Toresdahl et al., 2013).

Prior work in the cardiac arrest field has also focused on the implementation of PAD programs in sports-related settings, because cardiac arrest can sometimes be precipitated by an exercise-related event

(Drezner et al., 2009; Mitani et al., 2014). The most common underlying etiologies of cardiac arrest in athletes are hypertrophic cardiomyopathy (26.4 percent) (Maron, 2003) and commotio cordis (19.9 percent)—a sudden nonpenetrating blow to the chest that leads to ventricular arrhythmia (Maron, 2003). The estimated incidence of cardiac arrest in athletes varies from approximately 1 in 200,000 for high school athletes to approximately 1 in 43,770 for college athletes (Harmon et al., 2011; Maron et al., 1998). However, the true incidence is unknown because of the lack of a mandatory reporting (Drezner et al., 2005; Maron et al., 1998; Van Camp et al., 1995). However, the U.S. Sudden Death in Young Athletes Registry collects some data on these occurrences (Maron et al., 2006). The death of a seemingly healthy, young athlete can be a particularly devastating event for a community. As a result, several organizations (e.g., American College of Sports Medicine, the AHA, and the National Athletic Trainers’ Association) have recommended that universities make AEDs available at places where sporting events occur for the early intervention of cardiac arrest experiences by athletes and nonathletes who are attending sports events (Drezner et al., 2007). The use of AEDs has contributed to increased survival for some youth athletes (Drezner, 2009; Rothmier and Drezner, 2009).

In order to be effective, PAD programs in school settings must be well implemented (Drezner and Rogers, 2006; Drezner et al., 2005; Maron et al., 2002). Challenges that have been cited in responding to cardiac arrests in schools, including in student athletes, include “delayed rescuer recognition of [cardiac arrest], inaccurate rescuer assessment of pulse or respiration, delayed access to AEDs and delayed defibrillation, the presence of intrinsic structural cardiac abnormalities such as cardiomyopathies that may be more resistant to defibrillation with increasing delays in resuscitation, and increased catecholamine levels in athletes, which possibly increases the defibrillation threshold” (Rothmier and Drezner, 2009, p. 17).

Limitations in finances and personnel have also been cited as barriers to widespread implementation of AEDs and PAD programs in school settings. Nonetheless, many states—including North Carolina, Vermont, and Washington—are actively increasing the number of AEDs available on school campuses (Fields and Bright, 2011; Rothmier et al., 2007; Wasilko and Lisle, 2013). To use available funds in a cost-effective manner, AEDs could be placed in the places on campus where cardiac arrests are most likely to occur, and the public should then be made aware of their location (Moran et al., 2015). Overcoming funding limita-

tions will also require identifying funding from a range of sources (e.g., school districts, foundations, and fundraising) and assigning a program coordinator (e.g., certified athletic trainer) who is responsible for implementing the program and overseeing emergency responses (Rothmier et al., 2007).

First-Responder Programs (FRPs)

Cardiac arrest FRPs designed for law enforcement officers have also proven effective under some circumstances. The underlying concept of FRPs is that compared with EMS vehicle coverage, the density of police cars in a given area is higher. Therefore, it is possible that law enforcement could arrive at the scene of a cardiac arrest before EMS in a large proportion of cases (Mosesso et al., 1998). There may also be a benefit for arrests at home where law enforcement can be alerted of an event and an individual’s home address while the public would not be present and would not receive another person’s home information (Husain and Eisenberg, 2013). Adoption of FRPs has been slow but gradual, and programs have been implemented in select cities in states across the United States (e.g., Florida, Indiana, Minnesota, Ohio, and Pennsylvania) and cities in Europe (e.g., Amsterdam and London). Data from a metaanalysis of FRPs indicate that equipping police cars with AEDs generally led to decreases in time to defibrillation and improvements in individual patient outcomes (Husain and Eisenberg, 2013). However, not all FRPs have been successful: one PAD study did not demonstrate a statistically significant increase in survival rates, even though call-to-scene times were slightly reduced and the AEDs that were used by police officers marginally reduced the time from collapse to defibrillation (Groh et al., 2001). Another prospective controlled clinical trial of first-responder firefighters equipped with AEDs found that although this group arrived on scene before paramedics and the AEDs were effective and reliable, survival to hospital and discharge were similar to CPR-treated controls (Kellermann et al., 1993). The authors emphasized the importance of optimizing all links in the chain of survival for improved survival and that low rates of bystander CPR or delays in activating EMS may be barriers for achieving the full potential of early AED availability and use.

PAD Programs in Hospitals

While FRPs focus on improving AED access and use by trained responders, in-hospital PAD programs focus on enhancing AED access and use for both the public and health care providers (Laws et al., 2004). An estimated 1 percent of all in-hospital cardiac arrests are experienced by hospital visitors or staff when they are in hospital gift shops, parking lots, cafeterias, visiting areas, and other spaces throughout the hospital (Adams, 2005). While rapid response teams are in place in many hospitals, some hospitals also have AEDs installed for immediate use by bystanders and health care professionals until a hospital response team can arrive (Adams et al., 2006; Destro et al., 1996; Sommers et al., 2002). A Dutch study showed a reduction in hospital costs with early defibrillation and AED use, because of fewer days spent in the intensive care unit (van Alem et al., 2004). PAD programs in hospital settings are explored further in Chapter 5.

PAD Program Challenges

Despite abundant evidence that supports the potential benefit of PAD programs, there is substantial variability in how recommendations for CPR and AED training have been adopted across the United States (Haskell et al., 2009). The possible benefits offered by the placement and bystander use of AEDs in public locations have also been incompletely realized (Atkins, 2009; Axelsson et al., 1996; Deakin et al., 2014; Folke et al., 2009; Haskell et al., 2009; Hazinski et al., 2004; Kozlowski et al., 2013; Leung et al., 2013; McCartney, 2009; Merchant and Asch, 2012; Money et al., 2011; Platz et al., 2000; Schober et al., 2011; Shibata et al., 2000). The ability to track the progress of PAD programs in the United States is limited, because data regarding public AED locations, accessibility, use, and integration with local dispatch centers and EMS systems are generally unavailable. Studies comparing AED locations to the locations of actual cardiac arrests have concluded that AED resources do not often align with arrest occurrences. For example, Folke and colleagues (2010) showed that, in Denmark, many AEDs were placed in low-risk locations. In fact, of the 104 existing AEDs, only 29 would have covered cardiac arrests during the study period. Other studies have also shown variability in placement and use of AEDs by location (Merchant et al., 2013; Sasaki et al., 2011; Weisfeldt et al., 2010). Although specific locations for publicly accessible AEDs have been proposed, a definitive

strategy for AED placement in community settings throughout the United States has not been established (Chan et al., 2013; Folke et al., 2010).

To evaluate compliance with AED recommendations from the AHA, Haskell and colleagues (2009) developed a 25-point scoring scale to evaluate community PAD programs in Johnson County, Iowa (Atkins et al., 2009). The scoring system was modeled after the AHA’s four primary components of a PAD site (Hazinski et al., 2005) and included elements related to

• Planned and practiced response (e.g., employee training in CPR and AED; awareness of AED locations; existence of AED policies and emergency response protocols; AED access, availability, and maintenance),
• Links to local EMS, and
• Continuous quality improvement (e.g., post-event review, AED and personnel performance).

Two years after PAD programs were established in the county, no site was able to comply with all of the program recommendations. Problems including limited access to AEDs, limited awareness of AED locations, and expired pads or batteries were frequently associated with low compliance (Haskell et al., 2009).

A number of challenges have prevented the successful implementation of PAD programs throughout the United States. Determining a suitable, clearly marked location for an AED does not always happen, and encouraging facilities to participate in PAD programs and maintain AEDs is not always easy. There is also a general reluctance when it comes to public action in the case of emergencies that continues to hinder the success of PAD programs. Concerns about the possibility of adverse events with the use of AEDs have also been cited but are seemingly unsubstantiated.

Locating AEDs in Public Settings

Use of an AED in an emergency requires first knowing where the AED is located. In some places the process of finding the AED is formulaic and predictable. For example, almost all U.S. airports of a certain size have AEDs publicly displayed throughout their terminals. However, in other locations, the AEDs are out of public view, and other locations do not have an AED at all (McCartney, 2009). Also, knowing that an

AED is available does not necessarily equate to knowing where it is located in a building. In some buildings, AEDs are located in the main entrance in a well-marked box, while in others the AED may be in a desk drawer only accessible by a security guard or on a floor only accessible by a keypad. In some cases, AEDs are attached to doors or other objects without adequate identification (Haskell et al., 2009). This lack of uniformity makes locating AEDs a challenge for both organizations that are focused on tracking AEDs and for individuals who are looking to identify AEDs in an emergency (Leung et al., 2013; Merchant and Asch, 2012).

To date, estimates suggest that more than 1 million AEDs have been purchased in the United States in the past 20 years (Merchant and Asch, 2012). However, a national AED registry does not exist, and AEDs are not systematically mapped or tracked by communities, cities, or states. Geo-tracking devices offer promise for identifying devices in time and space for newly deployed devices, but it would be challenging to implement the use of this technology for existing devices, especially if the specific locations of the devices are unknown. Federal, state, and local regulations and recommendations could help standardize the location of AEDs and promote public awareness of those locations, but to date, these efforts have not gained necessary traction or momentum. Unlike other public awareness campaigns, such as going green or energy efficiency, promoting AED use within businesses or communities has not occurred. Although some buildings display a sticker on a front entrance that indicates an AED is inside, this may not be relatively common in heavily trafficked public buildings.

Other countries have taken action to track and increase the use of publicly available AEDs; these successes could provide useful models for similar efforts in the United States. For example, in some communities in Denmark, AEDs are registered in an accessible database that allows dispatchers to alert callers reporting a cardiac arrest of nearby AEDs. They are also able to actively reach out to nearby AED owners and notify the owner of the need for the device. This approach would require widespread AED registration and mapping. In these studies AED use was not reported (Hansen et al., 2013a; Nielsen et al., 2013). Also of note, as of 2008, ILCOR has adopted an International Organization for Standardization compliant sign for AEDs that is increasing in placement in Europe (ILCOR, 2008). Similar guidelines do not exist in the United States. There have been some efforts in the United States to register AEDs in dispatch systems, but one report of dispatchers using a PAD

registry found that very few OHCAs (8.4 percent) included the use of an AED (Rea et al., 2011).

Reluctance of Facilities to Implement or Maintain PAD Programs

Reluctance on the part of facilities to implement PAD programs is also a contributing factor to low adoption rates. Currently, there is an incomplete and disjointed dissemination of PAD programs nationally. Facilities that could participate in a PAD program have reported implementation barriers that include fear of litigation, difficulties associated with training personnel, developing facility-specific emergency response plans, and establishing around the clock response capability (Richardson et al., 2005). In schools, for example, prior reports cite a variety of barriers including funding, balancing time for training with additional scholastic requirements, scheduling, course content, and lack of equipment (Gundry et al., 1999). In some locations, AEDs have been donated to organizations, but the devices were not made publicly available (Haskell et al., 2009).

There is significant variability in AED regulations across states. Some states (e.g., California) “urge” schools to implement AED programs, other states (e.g., Virginia and Wisconsin) “require” AEDs in schools, while still other states (e.g., Tennessee) “encourage” placement in schools.⁹ In some states, day care center employees and dentists are required to have AED proficiency (National Conference of State Legislatures, 2012). Considerable variability exists in which PAD program components (e.g., site placement, training, maintenance, EMS/medical coordination, continuous quality improvement, and immunity) are mandated by states. Good Samaritan laws, AED prescription requirements, and appropriations for AED funding for example, may be very different when crossing from one state to the next. Although it is unclear how specific policies impact OHCA outcomes the documented effectiveness of AEDs for shockable cardiac arrest rhythms supports efforts to increase access and usability of lifesaving AEDs and improve uniformity in relevant policies.

________________

⁹For descriptions of current state legislation regarding AEDs in schools, see AHA, 2015a.

Reluctance of the Public to Act in an Emergency

Having a PAD program in place that includes AEDs installed in easily identified locations, a coordinated program, and plans for deployment and maintenance does not ensure success (Atkins, 2009). Not only do the devices have to be present, accessible, and in working order, but also individuals have to be willing to use them. Similar to CPR application, a low incidence of AED use by the public has been attributed to concerns about legal liabilities, limited knowledge, low rates of training, and limited access (Deakin et al., 2014; Hazinski et al., 2005; Kozlowski et al., 2013; Money et al., 2011; Schober et al., 2011). Further complicating the bystanders’ willingness to use AEDs, many of the devices are stored in cases with labels that incorrectly indicate that the device is for “trained professional use only.”

In 2013, Congress passed the Cardiac Arrest Survival Act of 2013 (Public Law 106-505), which specifically recommends that guidelines be developed for AED programs in U.S. federal government buildings. According to an AHA policy recommendation, the law also provides “limited immunity from civil liability for the emergency AED user and the AED acquirer if the state has not otherwise granted immunity for such persons under other statutes” (Aufderheide et al., 2006). Since its enactment, every state in the United States has instituted protection under the Good Samaritan laws for bystanders who use AEDs. Many states have also passed legislation that provides grants to state-level government agencies to purchase AEDs or requires (or strongly recommends) that AEDs are made available in certain locations such as fitness facilities or government buildings (Aufderheide et al., 2006). As the availability of AEDs in public locations such as transportation hubs, shopping malls, gymnasiums, schools, and federal buildings increases, so does the likelihood that a bystander will have immediate access to an AED. Therefore, CPR training should include instructions on the purpose and basic function of an AED.

AED Adverse Events

Ensuring that AEDs are safe for use as medical devices is one responsibility of the U.S. Food and Drug Administration (FDA). Adverse events related to AEDs are tracked in FDA’s Manufacturer and User Device Experience (MAUDE) database. Reporting to the database is voluntary. As such, reports generated from MAUDE may reflect un-

derreporting or over reporting. Also, FDA does not support the use of MAUDE for determining the incidence of device failure across devices that are currently in use. Prior studies from the MAUDE database that characterized more than 40,000 narratives that were available between 1993 and 2008 identified AED device failures such as devices not turning on, rhythm analysis not occurring, and devices spontaneously turning off unexpectedly (DeLuca et al., 2012). A subset analysis from data collected in the PAD study also reported adverse events with AED use (Peberdy et al., 2006). Of 649 cardiac arrest–related events, there were 27 AED-related adverse events (Peberdy et al., 2006). Those events were specifically attributed to theft of the device, AED placement in inaccessible locations, improper device maintenance, and mechanical challenges, none of which affected patient safety. Patient-specific adverse events were rarely reported from AED use in this trial, and no patient-related adverse events directly attributable to AED use were reported (Peberdy et al., 2006). In the PAD trial, no inappropriate shocks were delivered in the CPR-plus-AED group (Hallstrom et al., 2004). To date, reports in the literature of AED failures relating to direct patient harm are scarce. Future studies will be important for determining the incidence of device failures and characterizing the safety profile of these devices and their limitations.

OPPORTUNITIES

Despite challenges with adoption of PAD programs, several opportunities exist to promote the implementation of effective programs and improve outcomes from cardiac arrest in the United States. Social media, mobile media, and crowdsourcing are emerging as viable options to connect health resources and leverage citizen science—nonspecialists collaborating with scientist for research projects and initiatives (Scientific American, 2015). These emerging approaches also provide opportunities to enhance self-tracking and monitoring of PAD program progress to improve cardiac arrest survival and outcomes. Registries and other public data initiatives (e.g., Health Data Initiative, MyHeartMap Challenge) have the potential to make the identification of publicly available AEDs easier and could be used to link information to local dispatch centers and EMS systems (IOM, 2010; Merchant et al., 2013). Finally, achieving the full potential of AEDs may require a change in perspective: governments, health care organizations and professionals, and the public should

approach AED dissemination—and the programs that promote their availability and use—as public health initiatives akin to earlier efforts to install seat belts and airbags in automobiles, or fire extinguishers and sprinkler systems in public buildings (Mell and Sayre, 2008). The success of seat belt use at reducing death and disability was only realized once they came to be viewed as necessary public health interventions and their installation and use were required by law. Framing AEDs and AED programs in a similar manner may be crucial to achieving their full potential to save lives.

AEDs and the Potential of Social Media, Mobile Media, and Crowdsourcing

Several efforts have been specifically designed in order to improve and track AED location awareness and public knowledge through mobile media, social media, and crowdsourcing (Ahn et al., 2011; Bosley et al., 2013; Chang et al., 2014; Merchant and Asch, 2012; Merchant et al., 2013; Ranney and Daya, 2013; Sakai et al., 2011; Scholten et al., 2011; You et al., 2008). The potential of these tools is held in the billions of social media users, the millions of individuals engaged in crowdsourcing initiatives, and the ubiquity of mobile phones and smartphones. The fact that these platforms can be used for training, knowledge, data exchange, surveillance, just-in-time education, and direction to resources is of particular value to possible interventions. The digital divide is also narrowing as access to these digital resources is increasing across different socioeconomic groups, geographic regions, and age groups (Duggan, 2013; Madden, 2010; Mislove et al., 2011; Ranney and Daya, 2013).

The MyHeartMap Project is an AED-specific initiative that challenged individuals to locate, tag, and report AEDs using a smartphone app, social networking, and gamificiation (Merchant et al., 2013). In just 8 weeks, 852 AEDs in 528 buildings were located in Philadelphia, where only 57 AEDs had been catalogued previously (Merchant et al., 2013). Almost all of the devices (99 percent) that were reported by the public were independently validated by the research team (Merchant et al., 2013). This initiative demonstrates the potential of social media to engage members of the public as citizen scientists and to help create and maintain databases about AED information. A follow-up project called the Defibrillator Design Challenge targeted AED visibility and accessibility by using social media, crowdsourcing, and design to create artwork around the physical location of AEDs to make them more noticeable and

memorable (Kilaru et al., 2014a; Merchant et al., 2014). The project generated more than 100 virtually designed AEDs and garnered more than 50,000 votes and shares via Facebook and Twitter (Kilaru et al., 2014a; Merchant et al., 2014).

Other efforts—such as the PulsePoint Foundation in San Ramon, California—have focused on using smartphones to alert potential bystanders to cardiac arrest and AED locations in actual emergencies (PulsePoint Foundation, 2014). PulsePoint mobile apps share information about cardiac arrests in public locations with nearby bystanders. Occurring in real time, the alert system allows nearby participants to respond to the scene and use CPR and/or an AED for resuscitation. This program also uses crowdsourcing to empower bystanders to act quickly and responsibly in emergency situations.

Similar initiatives have also been tested in the Netherlands. Using text messages, an alert system notifies potential bystanders of nearby arrests and AED locations (Zijlstra et al., 2014). In 2013, a component of the ARREST study, used public campaigns and local advertising to identify bystander rescuers who were trained in CPR and AED use (Zijlstra et al., 2014). The program encouraged these trained bystanders to register their contact information (e.g., phone number and frequented addresses) in order to receive alerts about OHCA occurring within their close vicinity. AED locations were also registered and mapped throughout the community. This information was then linked with the local EMS dispatch system. The coverage area included two regions with approximately 1.2 million residents in total. After the program was initiated, an automated text messaging system was used to notify individuals within 1,000 meters of a presumed arrest. One-third of the bystanders were directed to the patient with cardiac arrest, and two-thirds of the bystanders were directed to retrieve a nearby AED. Over the course of the study, trained bystanders reduced the time to shock by 2 minutes and 39 seconds compared with EMS defibrillation, particularly in residential areas (Zijlstra et al., 2014). A recent Swedish study found that “a mobile-phone positioning system to dispatch lay volunteers who were trained in CPR was associated with significantly increased rates of bystander-initiated CPR among persons with out-of-hospital cardiac arrest” (Ringh et al., 2015, p. 2316). These findings provide a unique model for implementing AED registries, identifying individuals trained in CPR and AED use, linking this information with the EMS dispatch system, and using digital strategies for connecting responders with patients and AEDs in order to improve the public response to OHCAs.

Although not connected with digital technologies, similar efforts have been proposed for neighborhood-level PAD programs and response. Given the success of programs such as volunteer departments and neighborhood watches, neighborhood PAD programs have also been suggested as viable options for expanding the reach of AEDs (Zipes, 2001). In this context, neighbors trained in CPR and AED use could respond to nearby cardiac arrests. The call to 911 could simultaneously be routed to select neighborhood responders with the intent of decreasing the time to first chest compression or time to shock. This approach would require willing, trained, and available responders in neighborhoods with well-established cohesion and boundaries. This approach would also require further study before implementation in order to understand the necessary elements and potential impacts (Zipes, 2001).

Advocacy groups have successfully implemented PAD programs and lobbied state and federal legislatures for AEDs in schools, demonstrating the potential impact of engaging survivors, families, and advocacy groups in improving OHCA outcomes (Berger et al., 2004). The initiatives described in this section provide glimpses of the way in which social media, mobile apps, crowdsourcing, and communities can connect with available bystanders to enhance bystander response and increase AED awareness and use. Additional studies and pilot projects are needed in order to understand the opportunities, limitations, and benefits of digital tools and how these tools might complement existing infrastructure for individual and community response to cardiac arrest.

AED Registries

Registries represent one approach to overcoming the challenges associated with tracking AED locations and increasing the likelihood that an OHCA patient will receive bystander CPR and early defibrillation. Ideally, an AED registry would include not only information on AED location, but also linkages with EMS and bystander responders to capture data on structure, process, and outcomes (Bobrow, 2014; Merchant et al., 2013).

No comprehensive national AED registry exists in the United States. However, some existing cardiac arrest registries include a few desired AED variables. For example, the CARES database includes information about AED use, users, adjunct therapies (e.g., CPR, medications), and patient outcomes (McNally et al., 2011). The ROC Epistry includes data from all cardiac arrests with an EMS response and includes information

on whether an AED was used, cardiac arrest treatment, and outcome (Bradley et al., 2010; Weisfeldt et al., 2010). The MyHeartMap database includes publicly available data on AEDs located primarily in one state (i.e., Pennsylvania), and the National Registry for AED Use in Sports tracks AED utilization for athletes (Drezner et al., 2013; Merchant et al., 2013). Table 3-1 includes other examples of characteristics to consider for an AED registry.

Other countries are also making strides in implementing AED registries. As of 2013, an AED registry in the Netherlands had 1,550 registered AEDs (Zijlstra et al., 2014). As mentioned above, AEDs registry in combination with alerted lay rescuers have been shown to decrease time to defibrillation (Hansen et al., 2013b). In Japan, a registry program was able to increase the number of available AEDs in communities by more

TABLE 3-1 Ideal Characteristics of an AED Registry

than eightfold (Kitamura et al., 2010a). Over the study time frame, the use of AEDs by bystanders increased over time with improved favorable neurologic outcomes from 2.4 to 8.9 per 10 million individuals in the population (Kitamura et al., 2010a). Data from the Netherlands show that onsite AEDs saved 3.6 per 1 million inhabitants and doubled neurologically intact survival and were more beneficial than dispatched AEDs (Berdowski et al., 2011). Considering that 80 percent of arrests occur in the home and other nonpublic locations, further work is needed to evaluate the opportunities for optimizing AED availability, access, and use in these settings.

In-Home AEDs

To date, considerable time and energy have been focused on optimizing bystander and first-responder AED use in public locations, yet the majority of OHCAs occur at home and in private settings (Bardy et al., 2008). Studies and reviews of in-home AEDs have investigated the perceptions of having in-home AEDs available, training for high-risk patients and family members, potential impact of cost, and the possible impact on patient outcomes (Brown and Kellermann, 2000; Cagle et al., 2007; McDaniel et al., 1988; McLauchlan et al., 1992; Sigsbee and Geden, 1990). For example, the Home Automated External Defibrillator Trial evaluated the effectiveness of in-home AEDs for approximately 7,000 patients with a prior myocardial infarction who were not candidates for an implantable cardioverter defibrillator (Bardy et al., 2008). Patients were randomized to receive an in-home AED or not and were then followed for a total of 3 years. Of the 450 patients who died in the study time course, mortality rates were similar in the in-home AED group (6.4 percent) when compared with the control group (6.5 percent). The investigators concluded that access to an in-home AED did not improve outcomes when compared with the usual resuscitation response (Bardy et al., 2008). The study cited several reasons for the lack of a survival benefit, including the low number of witnessed cardiac arrests and the low proportion of AED use, even when the devices were available and the patient, spouse, partner, or other companions had been trained. Although case reports of AED use by parents for infants have been reported (Bar-Cohen et al., 2005; Divekar and Soni, 2006), randomized controlled trials for in-home AEDs have not been reported for pediatric populations.

Despite limited findings on the overall benefit of having an in-home AED available, the FDA allowed individuals to independently purchase AEDs without a prescription starting in 2004. Individuals who are interested in purchasing an in-home AED can currently buy one for personal use online via AED distributors, manufacturers, and other electronic commerce companies (e.g., Amazon). One of the notable benefits of AED devices is the easy-to-use visual and auditory instruction that is provided when the device is turned on. As noted previously, very little training or knowledge retention is necessary to successfully operate an AED regardless of its location. However, training for AED use is available through Web-based training programs, which can be used for training purposes in home settings. There are also mobile apps available that provide visual aids that detail AED use. These types of apps and Web-based training could provide just-in-time training in the home, but these approaches have not been formally tested for use in that setting or in comparison with more traditional training approaches.

CONCLUSION

The action of bystanders is pivotal to the success of the first three links in the chain of survival from cardiac arrest: early access (early recognition of cardiac arrest and calling 911), early CPR, and early defibrillation (use of AEDs). Although there is a multitude of evidence that indicates that bystander CPR can markedly improve survival, neurologic outcomes, and resulting quality of life, rates of bystander CPR in the United States remain adversely low, and less than 5 percent of the general public has been trained in CPR. Evidence also clearly supports the efficacy of placement and bystander use of AEDs in public locations. However, as little as 1 to 2 percent of EMS-treated cardiac arrests may receive early defibrillation from publicly available AEDs (Culley et al., 2014; Winkle et al., 2010). The implementation of multifaceted PAD programs throughout the nation remains adversely low, and the promise that these programs hold is incompletely realized.

The long-standing challenges of the public experience with cardiac arrest in terms of bystanders’ ability to recognize the arrest, initiate CPR, and use AEDs when they are available signals a clarion call for action. This call for action is supported by clear evidence that highlights the need for an immediate response following a cardiac arrest and the possibility of positive outcomes with a timely response. Widespread imple-

mentation of effective PAD programs and a renewed focus on CPR and AED training across communities are necessary to overcome persistent barriers in public engagement. Increased efforts to reach communities and populations where disparities are prevalent will also be necessary to promote change. An informed, coordinated, and effective public response to cardiac arrests across the nation would provide immense value to the overall health of the nation.

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