Papers

Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study

Jill P Pell, honorary clinical senior lecturer ^a, Jane M Sirel, research assistant ^a, Andrew K Marsden, medical director ^b, Ian Ford, professor of statistics ^c, Nicola L Walker, senior house officer ^a, Stuart M Cobbe, Walton professor of medical cardiology ^a. 

^a Department of Medical Cardiology, University of Glasgow, G31 2ER, ^b Scottish Ambulance Service Headquarters, Edinburgh EH10 5UU, ^c Robertson Centre for Biostatistics, University of Glasgow G12 8QQ

Correspondence to: Stuart M Cobbe stuart.cobbe{at}clinmed.gla.ac.uk

	Abstract

Top Abstract Introduction Methods Results Discussion References

Objective: To estimate the potential impact of public access defibrillators on overall survival after out of hospital cardiac arrest.
Design: Retrospective cohort study using data from an electronic register. A statistical model was used to estimate the effect on survival of placing public access defibrillators at suitable or possibly suitable sites.
Setting: Scottish Ambulance Service.
Subjects: Records of all out of hospital cardiac arrests due to heart disease in Scotland in 1991-8.
Main outcome measures: Observed and predicted survival to discharge from hospital.
Results: Of 15 189 arrests, 12 004 (79.0%) occurred in sites not suitable for the location of public access defibrillators, 453 (3.0%) in sites where they may be suitable, and 2732 (18.0%) in suitable sites. Defibrillation was given in 67.9% of arrests that occurred in possibly suitable sites for locating defibrillators and in 72.9% of arrests that occurred in suitable sites. Compared with an actual overall survival of 744 (5.0%), the predicted survival with public access defibrillators ranged from 942 (6.3%) to 959 (6.5%), depending on the assumptions made regarding defibrillator coverage.
Conclusions: The predicted increase in survival from targeted provision of public access defibrillators is less than the increase achievable through expansion of first responder defibrillation to non-ambulance personnel, such as police or firefighters, or of bystander cardiopulmonary resuscitation. Additional resources for wide scale coverage of public access defibrillators are probably not justified by the marginal improvement in survival.

What is already known on this topic Three quarters of all deaths from acute coronary events occur before the patient reaches a hospital Defibrillation is an independent predictor of survival from out of hospital cardiac arrest The probability of a rhythm being amenable to defibrillation declines with time Interest in providing public access defibrillators to reduce the time to defibrillation has been growing, but their potential impact on overall survival is unknown What this study adds Most arrests occur in sites unsuitable for locating public access defibrillators Arrests that occur in sites suitable for locating defibrillators already have the best profile in terms of ambulance response time, use of defibrillation, and survival of the patient Public access defibrillators are less likely to increase survival than expansion of first responder defibrillation or bystander cardiopulmonary resuscitation

	Introduction

Top Abstract Introduction Methods Results Discussion References

Defibrillation is an independent predictor of survival after cardiac arrests that take place out of hospital, after adjustment for ambulance response time and bystander cardiopulmonary resuscitation. Within 2 minutes of arrest, two thirds of patients have electrocardiographic evidence of ventricular fibrillation or tachycardia,¹ but the probability of a rhythm being amenable to defibrillation declines over time.² Even when an ambulance meets its target response time, some delay between the emergency telephone call and attendance is inevitable. Therefore, bystander interventions must be considered together with efforts to minimise ambulance response times. To shorten time to defibrillation, locating automated external defibrillators in public places, for use by bystanders before the arrival of the ambulance, has been considered. The Department of Health is committed to providing 700 public access defibrillators in 72 sites across England and Wales.³ The present study aimed to estimate the potential impact of public access defibrillators on overall survival after out of hospital cardiopulmonary arrest.

	Methods

Top Abstract Introduction Methods Results Discussion References

Setting
The Scottish Ambulance Service is the sole provider of emergency pre-hospital ambulance care in Scotland. During the period of study no public access defibrillators were deployed in Scotland. Pre-hospital defibrillations were undertaken by ambulance personnel (98.9%) or general practitioners (1.1%).

Data
Ambulance crews collect data on all resuscitation attempts after out of hospital cardiopulmonary arrests in Scotland. The forms include the time from the emergency telephone call to the arrival of the ambulance crew at the arrest scene, location of the arrest, and whether defibrillation was performed. Since 1991 the presumed cause of arrest has been classified in accordance with the Utstein convention, whereby arrests are defined as due to cardiac disease if the cause is recorded as heart disease or unknown or the record is missing.⁴ Forms completed by hospital staff document whether patients admitted to hospital after cardiac arrest survive to discharge. Data from both sets of forms are collated in an electronic register at Glasgow University.

Cohort study
Our cohort comprised all out of hospital cardiopulmonary arrests over a seven year period from May 1991 that fulfilled the Utstein definition of a cardiac cause, were not witnessed by the ambulance crew, and did not occur in an ambulance, ambulance helicopter, general practice, dental surgery, or non-acute hospital.

We reached a consensus on individual arrest sites that were suitable for locating public access defibrillators, possibly suitable (if defibrillators were to be very widely distributed), or unsuitable. In general, sites were given the benefit of doubt as to their suitability. Patients' homes were classified as unsuitable because, although automated external defibrillators are sometimes provided for use at home by patients judged to be at high risk of cardiopulmonary arrest, they are available only for personal use by trained family members and so are not accessible to the public. Unspecified sites were classified as possibly suitable. Actual survival to discharge was calculated for each of the three types of site.

Statistical model
Some patients have asystole from the onset of arrest and are unsuitable for defibrillation by the ambulance crew or bystanders. We assumed that public access defibrillators could increase the use of defibrillation up to a maximum equivalent to the use associated with early ambulance attendanceand therefore that survival would be improved, at best, to that obtained by early ambulance attendance. In each of the three suitability groups we divided arrests into those that were attended by the ambulance in 3 minutes of the emergency telephone call and those that were not. We calculated actual survival for each subgroup.

We calculated predicted survival in the suitable and possibly suitable sites by applying the survival rate among patients attended in 3 minutes to the number of patients who experienced a delay of >3 minutes. Calculations of the predicted numbers of survivors, survival rates, and associated 95% confidence intervals were made assuming that future arrests would have the same distribution of arrest sites and attendance times as the cohort data. We calculated two predicted overall survival rates, according to location of public access defibrillators only in suitable sites or in both suitable and possibly suitable sites. We calculated standard errors and 95% confidence intervals for predicted survival rates by propagating the binomial error from estimating the survival rates in the site groups and the time from emergency call to ambulance arrival through the formula for the estimated rates.

	Results

Top Abstract Introduction Methods Results Discussion References

Cohort study
Over the seven year study period, 21 481 cardiopulmonary arrests were attended by the Scottish Ambulance Service, and 15 189 fulfilled the inclusion criteria. Of these, 12 004 (79.0%) occurred in sites not suitable for the location of public access defibrillators, such as the person's home or a friend's home, 453 (3.0%) occurred in possibly suitable sites, such as buses and multistorey car parks, and 2732 (18.0%) occurred in suitable sites, such as shops, places of business, and sports centres (table 1). The 453 possibly suitable sites included 105 sites recorded only as "other" and three cases in which no information on site was recorded.

Data on defibrillation and outcome were available for 14 947 (98.4%) arrests. Of these, 8895 (59.5%) people received defibrillation from the ambulance crew (table 2). However, the proportion of people who received defibrillation varied significantly between unsuitable, possibly suitable, and suitable sites (P<0.0001). Just over half (56.2%) of the patients who had an arrest in sites not suitable for public access defibrillators received defibrillation, compared with 67.9% in possibly suitable sites and 72.9% in suitable sites. Less than 1% of patients who were not in ventricular tachycardia or fibrillation survived, irrespective of site of arrest. In all types of site, patients who received defibrillation were significantly more likely to survive. People who had an arrest in sites suitable for public access defibrillators had the highest baseline survival rate.

Overall, 70.1% of patients who were attended in 3 minutes received defibrillation, compared with 58.3% in patients who experienced longer delays (P<0.0001) (table 3). Among the 14 850 patients with complete data on ambulance response time and defibrillation, 744 (5.0% (95% confidence interval 4.7% to 5.4%)) survived to discharge from hospital.

Statistical model
The model predicted that locating public access defibrillators only in suitable sites would increase the number of survivors from 744 to 942, a survival rate of 6.3% (5.6% to 7.1%). If defibrillators were located in suitable and possibly suitable sites, the predicted number of survivors increased only slightly further to 959, a survival rate of 6.5% (5.7% to 7.2%) (table 3). In Scotland, with a population of 5.1 million, these rates equate to an average number of additional lives saved a year of 28 and 31, respectively.

A response time cut-off of 2 minutes rather than 3 minutes produced a predicted number of survivors of 1008 (6.8% (5.6% to 7.9%)) for suitable sites only and 1028 (6.9% (5.7% to 8.1%)) for suitable and possibly suitable sites. A cut-off of 4 minutes produced figures of 892 (6.0% (5.7% to 6.3%)) and 903 (6.1% (5.5% to 6.7%)).

	Discussion

Top Abstract Introduction Methods Results Discussion References

Our results show the limited impact of public access defibrillators on overall survival after cardiopulmonary arrest in a population. Most cardiopulmonary arrests occur in sites that are not suitable for locating public access defibrillators. Arrests that occur in obvious sites for locating defibrillators already have the shortest ambulance response times and the highest rate of defibrillation.

Reducing time to defibrillation
Nearly all survivors of out of hospital cardiopulmonary arrest are in ventricular fibrillation when the ambulance arrives, because asystole and pulseless electrical activity usually imply a prolonged interval from the onset of initial ventricular fibrillation or the presence of irreversible cardiac damage.⁵ The proportion of patients in ventricular fibrillation is inversely associated with time from cardiac arrest, with no evidence of a threshold effect. ^{2 6} Therefore, any intervention that reduces time to defibrillation should increase the proportion of patients suitable for defibrillation and improve survival.

The American Heart Association proposed four strategies to reduce time to defibrillation.⁶ Traditional first responders other than ambulance crews (such as police and firefighters) could be provided with automated external defibrillators and trained in their use. In Scotland provision of automated external defibrillators to other first responders could double overall survival to discharge from hospital.⁷

Formal training could be given to personnel not in the traditional emergency servicesflight attendants, security personnel, and voluntary workers. ^{8 9} An Australian airline installed automated external defibrillators in its aircraft and the airports it used.¹⁰ Over a period of 64 months 46 arrests occurred, 23 from ventricular fibrillation. Twenty one of these patients were successfully defibrillated and six survived. Similar results were reported in a more recent study of automated external defibrillators in a US airline.⁸ In a 32 month study on the use of automated external defibrillators by trained security personnel in 32 casinos, 148 people had a confirmed cardiac arrest. Defibrillators were used on 105 people whose initial cardiac rhythm was ventricular fibrillation. Overall 56 survived to discharge from hospital.

Automated external defibrillators could be provided to people at high risk of cardiopulmonary attack and to friends and family members trained in their use. Almost two thirds of all arrests occur in patients' own homes, and patients who have recently suffered a myocardial infarction or non-fatal arrest are at increased risk of cardiopulmonary arrest. However, these defibrillators would not be publicly available and would not reduce time to defibrillation among people not identified as at high risk or people in whom cardiopulmonary arrest is the first manifestation of cardiovascular disease, who account for most cardiopulmonary arrests in the population.

Finally, automated external defibrillators could be located in public places for use by the general public, most of whom will have little or no training in their use. This option is analogous to the situation in relation to fire extinguishers, which are widely distributed throughout public buildings. Public access defibrillators would need to take the form of simple, "intelligent" devices that require minimal training and maintenance and could be supported by telephone or interactive instruction.

Cost effectiveness
Making public access defibrillators as widely available as fire extinguishers would greatly increase early access but would incur considerable costs and would be problematic in terms of maintenance and avoiding misuse and vandalism. Nichol et al modelled the incremental cost effectiveness of expanding access to automated external defibrillators beyond the emergency medical services in the United States.¹¹ Their model excluded the 25% of arrests in the United States that occur in non-urban areas. They reported a baseline survival of 7.9%, which increased to a predicted 8.7% with lay responder defibrillation and to 11.8% with the police as additional first responders. The incremental costs per patient treated were estimated as $7100 (£4590; 7148) and $9200, respectively, and the cost per additional quality adjusted life year (QALY) was $44 000 and $27 200. The authors concluded that these costs were similar to those of a number of existing medical interventions. However, their lay responder model used costs from a police responder pilot. It is likely that the cost per QALY of a public access scheme will be much higher, owing to the large number of defibrillators needed to provide adequate coverage. Unlike automated external defibrillators used by a police service, public access defibrillators are fixed to a location, and the location of future arrests cannot be predicted precisely from the location of previous arrests.

Conclusions
Targeted placement of defibrillators in public places such as airports and shopping centres, frequented by a large number of susceptible people, could, at best, increase overall survival from 5.0% to 6.3%. These sites are the most suitable for locating public access defibrillators on grounds of effectiveness, cost effectiveness, maintenance, and training. People working in these areas could be trained in their use, rather than relying on the actions of untrained bystanders. Further expansion of the coverage of public access defibrillators to enable lay use in all potentially suitable sites would require much greater resources and would produce little additional improvement in survival. Public access defibrillators should not be provided in preference to the expansion of defibrillation given by first responders or increased cardiopulmonary resuscitation by bystanders.

	Acknowledgments

Contributors: SMC and AKM had the original idea for the study. SMC and JPP agreed the study design. JMS and NLW collated and processed the data. JPP and JMS undertook the analyses with advice from IF. JPP produced the first draft. All authors made comments on the paper, which was redrafted by JP. All authors agreed the interpretation of the results and read and approved the final draft. SMC is the guarantor.

	Footnotes

Editorial by Engdahl

Funding: British Heart Foundation.

Competing interests: None declared.

	References

Top Abstract Introduction Methods Results Discussion References

1.	Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM. The causative rhythm in out-of-hospital cardiac arrests witnessed by the emergency medical services in the Heartstart Scotland Project. Resuscitation 1994; 27: 55-59[CrossRef][ISI][Medline].
2.	Wilcox-Gok VL. Survival from out-of-hospital cardiac arrest. Med Care 1991; 29: 104-114[CrossRef][ISI][Medline].
3.	Secretary of State for Health. Saving lives: our healthier nation. London: Department of Health, 1999.
4.	Cummins RO, Chamberlain DA, Abramson NS, Allan M, Baskiett PJ, Becker L, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991; 84: 960-975[Free Full Text].
5.	Weaver WD, Hill D, Farhrenbruch ED, Coppas MK, Martin JS, Cobb LA, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 1988; 319: 661-666[Abstract].
6.	Nichol G, Hallstrom AP, Kerber R, Moss AJ, Ornato JP, Palmer D, et al. American Heart Association report on the second public access defibrillation conference, April 17-19, 1997. Circulation 1998; 97: 1309-1314[Free Full Text].
7.	Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ 2001; 322: 1385-1388[Abstract/Free Full Text].
8.	Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswamy K, et al. Use of automated external defibrillators by a US airline. N Engl J Med 2000; 343: 1210-1216[Abstract/Free Full Text].
9.	Valenzuela TD, Roe DJ, Nicol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000; 343: 1206-1209[Abstract/Free Full Text].
10.	O'Rourke MF, Donaldson E, Geddes JS. An airline cardiac arrest program. Circulation 1997; 96: 2849-2853[Abstract/Free Full Text].
11.	Nichol G, Hallstrom AP, Ornato JP, Riegel B, Stiell IG, Valenzuela T, et al. Potential cost-effectiveness of public access defibrillation in the United States. Circulation 1998; 97: 1315-1320[Abstract/Free Full Text].

(Accepted 2 April 2002)