From the Emergency Medical Services Division (L.B., M.E.), Seattle-King
County Department of Public Health, and the Department of Medicine (M.E.,
C.F., L.C.), University of Washington, Seattle.
Methods and Results—Locations of cardiac arrest were abstracted
from data collected by emergency medical service programs in Seattle
and King County, Washington, from January 1, 1990, through December 31,
1994. Types of commercial and civic establishments were tallied and
grouped into 23 location categories consistent with Standard
Industrial Codes, and the number of sites within each location category
was determined. With the addition of "public outdoors" and
"automobiles" as categories, there were 25 location categories.
During the study period, 7185 arrests occurred, 1130 (16%) of which
were in public locations. An annual incidence of cardiac arrest per
site was calculated. Ten location categories with 172 sites were
identified as having a higher incidence of cardiac arrest (
Conclusions—Placement of 276 AEDs in the 172 higher-incidence
sites would have provided treatment for 134 cardiac arrest patients in
a 5-year period, 60% of whom were in ventricular
fibrillation. We estimate between 8 and 32 lives could be saved in 5
years. To cover the remaining 347 arrests occurring in public in a
5-year period, defibrillators would have to be placed in 71 000 sites,
not including outdoors and automobiles. Placement of AEDs in public
locations can be guided by the site-specific incidence of arrest.
In Seattle and King County, Washington, the first emergency personnel
to arrive at the scene of a cardiac arrest are usually EMTs in a
vehicle equipped with a defibrillator. Paramedics are
simultaneously dispatched and arrive several minutes later.
Faster defibrillation might be achieved by placing defibrillators in
the community and training lay persons in their use. The purpose of the
present study was to determine the location and incidence of
cardiac arrest in public places to plan for the most efficient
placement of AEDs.
The place of arrest was routinely recorded on the medical
incident report. We classified the various places using SIC
codes.2 This is the classification standard that
underlies all establishment-based federal economic statistics. There
are unique SIC codes for every type of establishment, and the
establishments are listed in approximately the same way they appear in
the yellow pages of the telephone directory. By grouping
similar places, we compiled a list of 23 location categories. We added
2 categories, outdoors and automobiles, for a total of 25 location
categories. We calculated an annual incidence of cardiac arrest for
each location category; the number of arrests in each location category
in 5 years was divided by 5 and then by the total number of sites in
that category. Fire stations were excluded because they have
defibrillators on site. We included 106 privately operated ambulances
that did not have defibrillators on board. The denominator for vehicles
was the
There were 10 location categories that each had a relatively high
annual incidence of cardiac arrest,
The remaining categories had
The last 2 categories in Table 2
The distribution of defibrillators for the high-incidence
categories could be accomplished in many different ways and would
likely vary with each community. The following is a plan for placement
of the 276 defibrillators in our 172 higher-incidence categories. At
the international airport, there are 75 gates located in 15 clusters of
5 gates each. One defibrillator could be placed at each cluster. These
15 defibrillators would be used on 7 cardiac arrests per year. The
county jail has 11 floors. Due to security restrictions regarding use
of the elevators, efficient placement might consist of 1 defibrillator
per floor. The 3 shopping malls have a total of 27 entrances to the
outside; 1 defibrillator placed at each would provide coverage for 2
arrests per year. The 6 public sports arenas could have a total of 24
defibrillators, based on an average of 4 at each site, or 1
defibrillator per 15 000 spectators. They would be used in
Our study suggests that certain location categories would benefit
from public placement of AEDs. Our data do not address the issues of
cost-effectiveness, training requirements, maintenance of AEDs,
or likelihood that the devices would actually be used when needed. A
further limitation to the study lies in a certain amount of imprecision
in determining the number of sites per location category. For example,
in the retail business category, we were not able to discern how many
were mail-order or in-home businesses. Also, the construction site
category contains an unknown number of sites that were in operation for
only part of the study period.
Only
Planning for placement of AEDs in public should be guided by the
site-specific incidence of arrest. If we placed 276 defibrillators in
the 172 sites with the highest incidence, we would have the potential
for public access defibrillation for 134 arrests in a 5-year period,
Received January 27, 1998;
revision received March 24, 1998;
accepted April 3, 1998.
© 1998 American Heart Association, Inc.
Brief Rapid Communications
Public Locations of Cardiac Arrest
Implications for Public Access Defibrillation
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—The purpose of this study
was to describe the public locations of cardiac arrest and to estimate
the annual incidence of cardiac arrest per site to determine optimal
placement of automatic external defibrillators (AEDs). This was a
retrospective cohort study. 
.03 per
year per site). Thirteen location categories had a lower incidence of
arrest (
.01 per year per site). There were 
71 000 sites within
these categories.
Key Words: heart arrest • defibrillation • survival • resuscitation
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Placement of AEDs to
provide for public access defibrillation holds the promise of
shortening time from collapse to shock for VF, thereby improving
survival. Even a small decrease in time from collapse to shock is a
major factor in the VF survival rate. Because it is not realistic to
place an AED in every public location, identification of those places
in which cardiac arrest most frequently occurs should guide the
location of public access defibrillators to maximize their
usefulness.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
We abstracted data from EMS registries of cardiac arrest
in Seattle and King County, Washington (total population of 1.5 million
in the 1990 census). Data were abstracted for the period January 1,
1990, through December 31, 1994, and included presumed cause, address,
and location of arrest. A case was defined according to Utstein entry
criteria.1 In addition, the arrest had to have
occurred in a public place before the arrival of EMS personnel, and
resuscitation efforts had to have been undertaken by EMS personnel. All
ages were included. Arrests due to trauma were excluded because
defibrillation is not the first priority for most of these. A public
place was defined as an indoor commercial or civic establishment or
outdoors except immediately outside a patient's home. We excluded
private residences, nursing homes, and fire stations. Also excluded
were arrests in clinics or doctors' offices, on the grounds that an
unknown number of them may have had defibrillators available. The
majority of cases (89%) were due to presumed heart disease. The
remainder (11%) included other causes such as respiratory problems,
overdose, cancer, drowning, SIDS, neurological disorders, endocrine
problems, and anaphylactic shock. Etiologic classification was based on
field reports within the city and field reports, hospital records,
and death certificates within the county. 1 322 000 cars and trucks licensed in the city and county.
For the location category "outdoors," there was, of course, no
denominator.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
A total of 7185 nontraumatic cardiac arrests occurred before
arrival of EMS personnel in Seattle and King County during the study
period, and 1130 (16%) were in public places. Type of public place was
missing for 96 cases. We determined there were 71 000 public sites
in the 23 location categories, not including cars and trucks or public
outdoor locations. Location categories with the most sites were
nonretail businesses (33 662) and retail stores (17 390). Of arrests
in public, most locations were outdoors (32%; 385/1130) or in cars
(15%; 168/1130). .03 per site, or 1 arrest per
30 sites (1 arrest in 30 sites in 1 year is 1/30=.03). These are listed
in Table 1
. It would require 30 sites
in these types of location categories to yield 1 arrest per year. We
termed these the higher-incidence sites. Of these, the Seattle-Tacoma
International Airport had the highest incidence, with 7 cardiac
arrests per year. All these arrests took place in or near the terminal;
none occurred in the air. The ferry/ferry terminal/train terminal
category had an annual incidence of .1 per year. Stated differently,
each ferry, ferry terminal, or train terminal had 1 cardiac arrest
every 10 years, or a total of 10 ferries would have 1 passenger per
year experience a cardiac arrest. These 10 location categories, numbers
of arrests and sites, and annual incidence per site are summarized in
Table 1.
View this table:
[in a new window]
Table 1. Incidence of Cardiac Arrest per Site:
Higher-Incidence Location
Categories 1 arrest annually per 100 sites. These
are termed the lower-incidence categories. The data are summarized in
Table 2. For example, schools and
churches had an incidence of .002 per year, or 1 arrest per year per
500 sites, and retail stores had an incidence of .0005 per year, or 1
in 2000 sites per year. The concept of higher-incidence sites and
lower-incidence sites is reflected in a study from Dallas, Tex, that
described the incidence of cardiac arrest as low in high-rise office
buildings and high in the jail.3
View this table:
[in a new window]
Table 2. Incidence of Cardiac Arrest per Site:
Lower-Incidence Location Categories 
are arrests that occur in
vehicles and outdoors. A very low incidence occurred in vehicles (1
arrest per year per 10 000 vehicles), although with 168 arrests, this
category had the second-highest absolute number. The category
"outdoors" had the highest absolute number of cardiac arrests.
Obviously, there was no way to determine the number of sites in the
outdoors category. We estimate that it would take 276 defibrillators to
provide rapid defibrillation at the 172 sites with the higher incidence
of cardiac arrest. The number of defibrillators needed per location
category is shown in Table 1. Potentially, these defibrillators could
be used to treat 27 cardiac arrests per year. An average of 10 AEDs
would need to be placed in public settings to treat 1 cardiac arrest
per year.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
Public access defibrillation has the potential to increase
survival rates from cardiac arrest. As shown
elsewhere,4 survival is greater for individuals
who experience cardiac arrest in public places. These individuals are
younger, have fewer symptoms before arrest, are more likely to be in
VF, and are more likely to have a witnessed arrest with
bystander-initiated CPR. The survival rate of this group might be
further enhanced by strategic placement of defibrillators in the
community. Logically, the use of an AED located at or near the site of
arrest would achieve defibrillation faster than if resuscitation
efforts were delayed until the arrival of EMS personnel. 2
arrests per year. The largest manufacturing company, whose plants
account for 4 of the 14 sites in this category and >40 000 employees,
already has 1 defibrillator per site. There are 23 EMT vehicles located
throughout the plants. In the event of a medical emergency, an EMT is
dispatched simultaneously with the fire truck that
carries the defibrillator and usually arrives before the company fire
truck. If each EMT vehicle were equipped with a defibrillator, time to
defibrillation could be shortened. These 4 sites would require a total
of 23 defibrillators, which is 1 per 1500 employees. At this rate,
all the industrial sites would have a total of 46 defibrillators. Each
of the 47 golf courses, 11 homeless shelters, 18 health clubs, and 35
community/senior centers could have a defibrillator, as well as each of
the 10 ferries and 3 ferry and train terminals. 16% of arrests occur in public. We did not consider other
factors that influence outcome, such as witnessed arrest, bystander
CPR, or rhythm on arrival (60% were in VF on arrival of EMS personnel
in the present study). On the basis of 80 VF arrests in the
highest-incidence sites (60% of 134 cases) with a survival rate
between 10% and 40%, we estimate that between 8 and 32 lives might be
saved over a 5-year period with distribution of the 276 defibrillators
proposed in Table 1. 80 of which would have an initial rhythm of VF. However, to cover
the remaining 347 arrests in public, defibrillators would have to be
placed in >71 000 sites, not including automobiles or outdoors. We
conclude that placing defibrillators in public locations is a
reasonable strategy, but probably only in locations with relatively
high incidences of arrest. We suggest that each community identify
those sites with high incidences of cardiac arrest to plan for rational
placement of AEDs.
Selected Abbreviations and Acronyms
AED
=
automated external defibrillator
EMS
=
emergency medical services
EMT
=
emergency medical technician
SIC
=
Standard Industrial Classification
VF
=
ventricular fibrillation
Acknowledgments
Support for this project was provided by the Emergency
Medical Services Division of the Seattle/King County Health Department
and the Medic One Foundation. We thank Tracey Walsh and Stefanie
Ostergard for help in data collection and Richard Cummins, MD, for
manuscript review and helpful suggestions.
Footnotes
Reprint requests to Linda J. Becker, MA, Emergency Medical Services Division, 999 3rd Ave, Suite 700, Seattle, WA 98104.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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