Correspondence to Richard S. Hamburg, MPA, 1150 Connecticut Ave, Room 810, Washington, DC.
all communities should adopt the principle of early
defibrillation. This principle applies to all personnel who are
expected, as part of their professional duties, to perform basic CPR:
They must carry an AED and be trained to operate it. Health
professionals who have a duty to respond to a person in cardiac arrest
should have a defibrillator available either immediately or within 1 to
2 minutes. Responsible personnel should authorize and implement more
widespread use of automated external defibrillation by community
responders and allied health responders.1
Unfortunately, the nature of prehospital medical care (including
training, equipment, and standards of care) varies widely from state to
state, which results in inconsistent care for the public. The
1996 poll of state EMS directors, released in January 1997, found that
only 27 states permitted, through enabling legislation, non-EMT first
responders to use AEDs. In only 6 states are lay rescuers allowed to
use AEDs: California, Florida, Maine, Maryland, North Dakota, and
Texas. Individual recommendations by the state EMS directors included
(1) the development of model legislation; (2)
fostering of federal initiatives to fund the purchase of AEDs; and (3)
training of all non-EMT firefighters, police officers, and
other public safety first responders in the use of
AEDs.3
This is, however, a far cry from the status quo of only 5 to 10
years ago. As late as the early 1990s, very few EMTs were authorized to
use AEDs. By 1994, however, 36 states had laws or regulations to allow
EMT defibrillation, and by 1997, nearly all states authorized use of
AEDs by EMTs. The spread of EMT defibrillation was enhanced by the
publication of the US Department of Transportation's 1994 EMT basic
national standard curriculum, which sanctioned training EMTs to operate
and maintain AEDs.
"Historically, one of the fundamental challenges facing proponents of
early defibrillation initiatives has been the need for legislation to
enable various levels of health care professionals, public safety
personnel, and in some cases, lay citizens to use AEDs. In most states,
AED use is considered a medical act (68 percent) and individuals who
use AEDs are required to be certified or licensed (78
percent)."4
As far back as 1989, the American Medical Association Commission
on EMS adopted a resolution that recognized that the use of AEDs by
trained and medically controlled initial scene responders other than
ambulance personnel has been shown to improve survival. The commission
encouraged states to "adopt laws and/or regulations to facilitate
early defibrillation, using such technologies as AEDs, without
unnecessary personnel certification restrictions."
Numerous other groups have since followed suit. Last year, the National
Heart Attack Alert Program, representing a broad range of
public health groups, stated during its quinquennial retreat the
following goals: (1) to increase the concept of the chain of survival
for acute myocardial infarction: early access to the EMS system, early
CPR, early defibrillation, and advanced life support; (2) to increase
the percentage of EMTs and first responders who are trained to operate
AEDs; (3) to increase the percentage of patients with out-of-hospital
cardiac arrest discharged alive; and (4) to decrease the time from call
to EMS dispatch to arrival at the scene of defibrillation.
A well-trained EMT aboard a fire engine or an ambulance can clearly
make a difference, but all too often, lifesaving equipment isn't along
for the ride. Most important is a portable defibrillator, "...
[yet] not even one third of the nation's ambulances and fewer than
five percent of all fire engines are equipped with
one."6
A 1995 survey of fire department operations by the Phoenix (Ariz)
fire department shows the importance the fire department places on
rapid response to both fire and EMS incidents. In Phoenix, the average
response time for a fire department first responder/EMS-capable vehicle
is 4 minutes and 15 seconds. The Phoenix Survey confirmed that fire
departments provide advanced life support services in more than half
(59%) of all cities in the United States and nearly 80% of US cities
with populations greater than 1 million.7
In 1990, the Hamilton, Ontario, fire department launched a program to
train 450 firefighters to use AEDs. A subsequent study revealed that
firefighter first responders were able to substantially reduce time to
defibrillation.8
In a recent survey of out-of-hospital ventricular
fibrillation treated by defibrillator-equipped police and
EMT-paramedics, survival to discharge was 49%, including 58% of those
initially treated by police. All of the police officers were
trained as first responders in accordance with the US Department of
Transportation First Responder Training
Program.9
According to AHA guidelines, "... all personnel whose jobs require
that they perform basic CPR [should] be trained to operate and
permitted to use defibrillators, particularly AEDs... . The AHA
considers early defibrillation the standard of care in the community.
Failure of emergency personnel to have a defibrillator available during
a cardiac arrest is difficult to defend."10
At the state level, there has been a recent flurry of activity to
expand access to AEDs. In Florida, legislation was recently signed into
law that expressed the intent of the legislature that an AED may be
used by any person for the purpose of saving the life of another in
cardiac arrest. Under the legislation, all persons who have access to
or use of an AED must obtain appropriate training, to include
completion of a course in cardiopulmonary resuscitation or
successful completion of a basic first aid course that includes
cardiopulmonary resuscitation training and demonstrated
proficiency in the use of an AED.
The Florida state Good Samaritan law was also amended to require
that persons, including those licensed to practice medicine, who
gratuitously and in good faith render emergency treatment and/or
treatment by the use of or provision of an AED, without objection of
the injured victim or victims thereof, shall not be held liable for any
civil damages as a result of such treatment or as a result of any act
or failure to act in providing or arranging further medical treatment
where the person acts as an ordinary, reasonably prudent person would
have acted under the same or similar circumstances.
The new law replaced previous language requiring successful completion
of 6 hours of training in the use of automated or semiautomated
defibrillators. "The new state legislation on AEDs, a model for a
version that's soon expected to be introduced nationally, is designed
to promote widespread use of AEDs by easing training and other
bureaucratic requirements."12
In Tennessee, state regulations authorize first responders and EMTs
trained in an appropriate program to perform defibrillation on a
pulseless, nonbreathing patient with an automated-mode device.
A recent law in Louisiana allows certified first responders to use AEDs
in accordance with a protocol that shall be approved by the local
parish medical society, or its designee, and the local physician
medical director.
In July 1997, legislation was signed into law in Nevada
encouraging all employers who are required to establish a written
safety program to employ a person who has successfully completed a
course in basic emergency care of a person in cardiac arrest that
includes training in the operation of an AED.
In Massachusetts, legislation was introduced during the 1997
legislation session to replace the existing good Samaritan law and
expand its focus to include the use of semiautomated or automated
defibrillators. Under the legislation,
any person trained according to the standard guidelines of
the American Heart Association or American Red Cross in CPR and/or the
use of semi or automatic external defibrillators, or any person who has
successfully met the training requirements of a course in basic cardiac
life support, according to the standards established by the AHA, who in
good faith renders emergency CPR and/or defibrillation in accordance
with his/her training, to any person who apparently requires
cardiopulmonary resuscitation and/or defibrillation, shall not
be liable for acts or omissions, other than gross negligence or willful
or wanton misconduct, resulting from the rendering of such emergency
cardiopulmonary resuscitation and/or defibrillation.
To make its case to legislators, the AHA Massachusetts
Affiliate pointed out in its supporting materials that the "new
generation of AEDs will make it more practical to train and equip a
wider range of responders, including fire department personnel, police
officers, lifeguards, flight attendants, security guards, and
others responsible for public security. Public Access Defibrillation is
the ultimate goal as a result of this new technology. This will mean
the general public will have access to [AEDs] in highly populated
areas such as office buildings, stadiums and airplanes, where survival
rates from sudden cardiac arrest are less than 1 percent.
"The use of [AEDs has] become industry standard training for
emergency personnel. The technology has made the device cheaper to
purchase and has become an invaluable tool in saving human
life."13
The preamble to the Hawaii statute states that "the legislature finds
that all personnel whose jobs require the performance of basic
cardiopulmonary resuscitation (CPR) should be trained to
operate automatic external defibrillators as recommended by the
American Heart Association."
There is clearly a need to revise Good Samaritan laws across the
country to protect good-faith efforts to revive those suffering sudden
cardiac arrest. "Would-be AED users perceive a heightened legal risk
flowing from the acquisition, deployment and use of the device. The
current state of negligence law appears to support this
perception."14
Interestingly, a new legal trend is in the making. In 1996, Busch
Gardens was found negligent in a case for not providing an adequate
emergency response plan, including a lack of access to the use of
defibrillators. Lawyers for the plaintiff argued that Busch Gardens had
trained nurses and EMTs on site at all times who ought to have been
provided the technology to resuscitate heart attack victims. In
addition, a federal judge found Lufthansa Airlines negligent for
failing to provide timely treatment for a patient suffering a cardiac
arrest. This points out the concept of breach of duty, in which an
individual or body was deemed to have an obligation to perform a duty,
in this case, defibrillation.14
On Representative Studds' retirement at the end
of 1996, the AHA, the American Red Cross, and its coalition partners
began a process of redrafting the Cardiac Arrest Survival Act and
securing a new sponsor for the legislation. On May 20, 1997,
Representative Cliff Stearns (R-FL) introduced a
retooled version of the Cardiac Arrest Survival Act. By February 1998,
the legislation had been cosponsored by a bipartisan group of 80
members of the House of Representatives.
The legislation would establish a federal program regarding
training in life-saving interventions and the use of life-saving
equipment, including AEDs, to assist individuals experiencing cardiac
arrest. Specifically, the legislation calls for (1) the National Heart,
Lung, and Blood Institute, in cooperation with the National Highway
Traffic Safety Administration, to develop and disseminate a model state
training program for first responders and bystanders in life-saving
interventions, including CPR; (2) the development of model state
legislation to ensure access to emergency medical services, including
consideration of the necessary location and placement of life-saving
equipment, including AEDs; the development of requirements for training
in the core content and use of life-saving equipment, including AEDs;
and the provision of good Samaritan immunity for bystanders, first
responders, instructors, and owners and managers of property where
equipment is placed; and (3) the development of a national database for
reporting and collecting information relating to the incidence of
cardiac arrest and whether interventions, including bystander or first
responder interventions, improve the rate of survival.
Highlights of the legislation that broadens the model federal EMS
program include (1) clinical evaluation of the results of proposed
interventions to ensure timely and appropriate changes in the
curriculum and (2) development of a uniform national standard on the
appropriate use of lifesaving equipment for first responders,
bystanders, and other persons who may volunteer to resuscitate patients
but are not trained paramedics or EMTs.
The legislation is supported by more than two dozen national
organizations, including the AHA, American Red Cross, American Academy
of Pediatrics, American College of Emergency Physicians, International
Association of Fire Chiefs, and National Association of State EMS
Directors.
Also, federal legislation was introduced by
Representative Barbara Kennelly (D-CT) that would
require the inclusion of AEDs as part of the on-board medical kits used
by commercial US flights. In July 1997, American Airlines followed
through on a November 1996 announcement to equip all of their
over-water flights with AEDs. Approximately 300 AEDs will be carried on
international flights and some domestic over-water routes. All American
Airlines in-flight personnel will now be trained to use AEDs.
Finally, the Fiscal Year 1998 US Department of Transportation
Appropriations bill committee report includes language stating
that11 the use of AEDs by emergency responders can
significantly improve cardiac arrest survival rates. To ensure that
training standards for use of AEDs are not unnecessarily burdensome and
are consistent with now easy-to-use AED technology, the
Committee encourages the Secretary to work with state departments of
transportation and other appropriate state agencies to review their
defibrillator training requirement and to modify these requirements
where appropriate.
Conclusions
© 1998 American Heart Association, Inc.
Special Reports
Automated External Defibrillators
Time for Federal and State Advocacy and Broader Utilization
Key Words: defibrillation • death, sudden • fibrillation
Introduction
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
More
than 6 years ago, the AHA published Improving Survival From Sudden
Cardiac Arrest: The "Chain of Survival" Concept. The paper
identified the idea that
Current EMT and First Responder Preparedness
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
A 1995 poll of state EMS directors, published in the Journal
of Emergency Medical Services, identified obstacles to
implementation of early defibrillation programs. Among the major
obstacles was a lack of enabling state legislation (34% of
respondents).2 According to a subsequent 1996
survey of state EMS directors, fewer than half of EMTs and fewer than
one quarter of non-EMT first responders in the United States were
trained and equipped to defibrillate.3
Lives Saved by First Responders
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
The survival rate from cardiac arrest in Boston has risen by 50%
(from 16% to 24%) since 1994, when Boston began a program to train
firefighters to use AEDs. Boston has added 5 new ambulances, 100 AEDs,
and 135 EMTs to its First Responder Defibrillator Program and trained
all of its 1650 firefighters in CPR and defibrillation. Boston EMS had
previously purchased 85 AEDs.5
States Move to Authorize First Responder
Defibrillation
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
Concerted community-based action is needed to ensure
widespread access to early defibrillation. Advocates for the chain of
survival need to educate key decision-makers about the importance of
AEDs, ensure that laws are in place that allow all first responders to
administer defibrillation, provide all first responder vehicles with
access to AEDs, and ensure implementation of current
laws.11 The laws and regulations addressing
training requirements should be flexible enough to adjust to changes in
state-of-the-art AED technology.
Federal Legislative Actions Pursued
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
AHA federal legislative actions on the AED issue began in earnest
in late 1994 with the commencement of discussions with US
Representative Gerry Studds (D-MA) and his staff, which
eventually led to development of a comprehensive bill addressing the
links in the chain of survival. In early 1996, the Cardiac Arrest
Survival Act was formally introduced in the House of
Representatives on March 6, 1996.
We expect further progress on federal and state levels to remove
barriers to the chain of survival. Expanded use of AEDs is essential to
ensure the success of these efforts.
Selected Abbreviations and Acronyms
AED
=
automated external defibrillator
AHA
=
American Heart Association
CPR
=
cardiopulmonary resuscitation
EMS
=
emergency medical service
EMT
=
emergency medical technician
Footnotes
Reprint requests to Pat Bowser, 3603 Reposo Way, Belmont, CA 94002.
References
Top
Introduction
Current EMT and First...
Lives Saved by First...
States Move to Authorize...
Federal Legislative Actions...
References
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