AED in public area
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This document summarizes evidence and opinions on automated external defibrillators (AEDs) in public areas. It discusses cardiac arrest statistics globally and in Asia, lessons learned from public access defibrillation programs, and the current situations of PAD programs in several Asian countries. The key lessons are that AEDs must be accessible, retrievable, and strategically placed based on data about locations of cardiac arrests in order to maximize survival benefits from public AED deployment.
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AED in public area
- 1. Automated External Defibrillators in Public Areas : The Evidence And Opinion 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Nalinas Khunkhlai MD FRCPT(Emergency Med) Scientific chairman Thai Resuscitation Council Department of Emergency Medicine and Narenthorn EMS Center, DMS, MOPH THAILAND
- 2. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Conflict of Interest statement : None
- 3. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Cardiac arrest : By location OHCA IHCA Residential ~65% Public
- 4. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Survival rate?
- 5. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Cardiac arrest statistics : US US OHCA survival Adult (%) Children (%) Overall (%) Bystander witness + VF Survival to discharge 28.4 57.1 28.4 - From survey , 79% Public knows what to do. - 98% recognised for shock the heart back to normal. - 60% familiar with CPR - 60 % were treat by EMS ~40% bystander CPR with AED - For EMS treat group : 23% VF Circulation 2013 : 127; 000-000
- 6. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Cardiac arrest statistics : Asia - Largest database came from Japan, Korea, Singapore and Taiwan. - Bystander CPR rate varies among countries. - Available OHCA data . For IHCA - very limited. PAROS Investigators group. OHCA Asia Bystander CPR (%) AED (%) Overall survival + CPC 1-2 (%) Korea 42.4 0.3 3 Japan 40.2 0.7 2.8 Singapore 24.3 1.1 1.7 Malaysia 22.6 NA NA Taiwan 19.8 NA 3 Thailand 15.8 0.3 1.7 UAE 10.5 0.8 3 Overall 38.3 0.6 2.8 Asian OHCA survival Adult (%) Children (%) Overall (%) Bystander witness + VF Survival to discharge Unknown
- 7. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY
- 8. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Lesson learned from PAD program.
- 9. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Victim Rescuer AED Out of hospital part From chain of survival.
- 10. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY AED is good Only when the Rescuer can find them !!!! Lesson No.1= can’t find
- 11. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Resuscitation 84 (2013) 910-914 Philadephia : Located the AEDs. - Philadephia : 1420 buildings Door-to-Door survey - 12% of buildings report AEDs in place. - Confirm by visualization and photo for 53%. …. Others : employees refused access. (Average 67% of buildings allow public access.) - In the building with AED : need to contact at least 2 employees (range 1-8) before take the AED for use. - Average time to get AED 4 minutes (range 1-55)
- 12. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY AEDs were placed in the place which mostly restrict access. Resuscitation 84 (2013) 910-914
- 13. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Copenhagen 1994-2011 : OHCA in public places - AEDs registered with Danish AED Network,Denmark. - Mark decrease accessibility in evening and Night time. and weekdays. Malta Hansen et al. Circulation. 2013; 128:2224-2231 Lesson No.2 = can’t get
- 14. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Malta Hansen et al. Circulation. 2013; 128:2224-2231 Copenhagen 1994-2011 : OHCA in public places - AEDs hardly access during non-weekday-daytime.
- 15. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Lesson No.3 = can’t plan What data is need before the planing? point of risk for OHCA vs Place for AED
- 16. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY PAD in Toronto : GIS modelling to match cardiac arrest location with possible AED sites A.A. Siddiz et al Resuscitation 84 (2013) 904-9 - 15,786 OHCA non traumatic cases in Great Toronto. - 1,754 (12%) arrest in public locations. - 1,310 cases in Toronto Only. - 44.4% Bystander Witness - 38.1% Bystander CPR - 5.3% Bystander AED - 32.1% Shockable rhythm - 12.2% Survival to hospital discharge
- 17. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY A.A. Siddiz et al Resuscitation 84 (2013) 904-9
- 18. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Best coverage calculation at 100 AEDs with 40% cases area coverage A.A. Siddiz et al Resuscitation 84 (2013) 904-9
- 19. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY At Ratio 1 AED for 40 m. - Increasing coverage from 15% to 20 % needs 70 AEDs At Ratio 1 AED for 100 m. - Increasing coverage from 15% to 20 % needs 15 AEDs A.A. Siddiz et al Resuscitation 84 (2013) 904-9
- 20. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Lesson No.4= can I? Previous MI Should I have AED at home?
- 21. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Home use of AED for Sudden cardiac arrest Home Automated External Defibrillators Trial : HAT Investigators NEJM 2008; 358: 1793-804 - 7000 anterior MI , who were not candidates for ICD - Control group = Call EMS + perform CPR - AED group = Use AED + then call EMS + perform CPR Primary outcome = death (any cause) Control 6.5% vs AED 6.4% HR AED 0.97 (95%CI 0.81 to 1.77 , p 0.77) Home AED did not improve overall survival , compared to conventional resuscitation methods.
- 22. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Factors to make maximum benefit from having AEDs Victim Rescuer AED Register maintain easy access quality control in touch with local emergency centre High ‘possible victim’ traffic High risk activity (sports) local officer as response FR volunteer rescuers High density Willing & knowledge
- 23. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY AED placement ? : the magic numbers - High Incidence sites ?( ≥ 1 arrest per 30 sites in 1 year) - Low Incidence sites ?( ≤ 1 arrest per 100 sites in 1 year) - Places of high flow of possible victims ( ex. Airport / prison / shopping malls ) - Places of high risk activities ; physical (sports center) or mentally (casino). Becker L. et al. Circulation 1998; 97:2106-9 CB Lo. Hong Kong Med J (9) 2003; 114-8 Should analyse your area incidences Strategic plan before deploy.
- 24. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Current situation of PAD program in Asia
- 25. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Situation of PAD program in Asia - Japan - Korea - Taiwan - Singapore
- 26. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY NEJM 2010; 362:994-1004 - All-Japan Utstein Registry ; 2005 to 2007 - 312,319 adults OHCA - Presumed cardiac + Bystander witness + Initial VF = 12,631 (4%) - Of 12,631 OHCAs, 3.7% AED by Layperson.
- 27. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Temporal trend of Public OHCA : Japan 11 13 19 0 5 10 15 20 25 2005 2006 2007 OHCA : Bystander CPR+ witness + VF Survival to hospital discharge with CPC1-2 (%) 24 29 34 0 9 18 27 36 45 2005 2006 2007 OHCA : Receive AED shock Survival to hospital discharge with CPC1-2 (%) NEJM 2010; 362:994-1004
- 28. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY 24 29 34 0 9 18 27 36 45 2005 2006 2007 OHCA : Receive AED shock Survival to hospital discharge with CPC1-2 (%) Time from collapse to 1st shock (min) 3.7 3.2 2.2 NEJM 2010; 362:994-1004 PAD Japan
- 29. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Murakami et al. J Am Heart Assoc. 2014; 3: e000533 OHCA outcomes after PAD era in Osaka - Osaka, Japan. From 2005 through 2011. - 9453 bystander witnessed OHCA. - 9.5% occurred in public place - Mean time from collapse to shock = 5 min Trends in proportion of Public AED use by laypersons, bystander witnessed OHCA AEDs use from 2005 to 2011 2005 2011 Railway 0 41.2 Sports facility 0 56.5 Proportion of good CPC (%) Sports facility School Railway Public building 51.6 41.9 28 23.3
- 30. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY PAD in Korea Hyun Soo Chung Resuscitation 84 (2013) e95-e96 Using Digital Signage stand with AED inside Seoul , August 2011 Benefit : - 1. cost : get money from advertising. - 2. user-friendly , easy to learn - 3. more approachable to small-scale communities Ads
- 31. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Marcus EH Ong et al. Resuscitation 2008; 76,388-396 Singapore : PADS Phase I Geographic information systems for planning Public Access Defibrillation? Distribution of OHCA were different compare day time to night time.
- 32. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Singapore : Public Education / AED registry
- 33. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Taipei : Geospatial analysis of OHCA / 7-11 coverage - Green dot = OHCA - Purple dot = 7-11 location - Orange dot = Fire station Chung-Yuan Huang, Tzai-Hung Wen. Computational and Mathermatical methods in Medicine. May 2014
- 34. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Taipei : Geospatial analysis of OHCA / 7-11 coverage Chung-Yuan Huang, Tzai-Hung Wen. Computational and Mathermatical methods in Medicine. May 2014 Comparison of coverable OHCA rates for different AED service range when 7-11 is limit to 100 stores
- 35. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Victim Rescuer AED Conclusion PAD program returns the good survival chance Only with initial area assessment continuous monitoring and re-evaluation.
- 36. 20th ASEAN Federation of Cardiology Congress 2014, June 12th -15th, Kuala Lumpur, MY Thank you
Editor's Notes
- Cardiac arrest divided by location. For OHCA take greater number of patients but also much lower chance of survival when compare to the In-hospital arrest.
- Public location can be either airport or train station, In sports facilities , golf course . Be witnessed and receive bystander help are the pivotal factors to survive.
- Let’s have a look on OHCA statistics in the US 79% of public knows to call emergency number and start chest compression. Many of them know what AED is and for. Even better that more than half familiar with chest compression only CPR. About bystander AED , 40% of cases received the shock. Overall survival rate is 9.5% In good case like bystander witness , receive CPR and initial EKG was shockable rhythm. The survival to discharge drive up to 28.4%
- How about our region? Due to large varieties of emergency health systems’ characteristics in each country . Hardly to get the collaborate data Large database came from Japan , Korea , Singapore and Taiwan. Bystander CPR rate range from 10 to 40 % , quite same as US data but very low AED use So came up with “overall survival to hospital discharge” rate is not more than 3%.
- To save a man who arrest out there. We trained layperson to do chest compression. We places the AED everywhere. Start Public access defibrillation Program.
- For about 15 years worldwide. We found many interesting points about PAD program.
- PAD program try to bring these 3 components together while awaiting for the ALS team.
- One study in Philadephia search over 1,500 building found only 12% of them have AEDs in place. Confirm the present of AED by visualise or take photo only 53%, the rest of AED were in the restrict area / hard to access. To get AEDs in case of emergencies. Need to contact at least 2 employees in the building before get the AED. Average time to get AED was 4 minutes. ( and the maximum time to get AED was 55 minutes).
- AEDs, which should be accessed easily when need, turn to be found out placing in the restrict area like government building / Office / Medical center / Gym. Public area like retail stores or restaurant, had only few AEDs. However , this report did not state whether those AEDs were belonged to private company or they were actually belong to local emergency response unit.
- The other accessibility problem is the location of AEDs were restrict by weekend and after work hour. From Danish AED network, It became hardly to get AED after work hour.
- While the need still persist. These limitation is important obstacle for AED registry to concern.
- 7000 anterior MI who’re not candidate for ICD were randomised into control and AED group. Control protocol was call EMS and perform CPR once pt collapse. For AED group : Use AED then make a call and CPR. Without any statistical significant different on baseline characters for both groups. The kaplan meier curve for death of any cause show no statistical significant different between both group. Home AED compare to conventional CPR did not make any significant improve overall survival.
- So all these are common factors need to be analyse before you invest the money into the PAD program. 1.Weak link on Rescuer leads to having AED but no one give a hand. 2.Weak link on Victim leads to miss the high risk high flow and loss the chance to shock the heart back. 3. Weak link on AED leads to waste the budget, left the AED over and not ready for use. Buy the AED but can’t tract where they are. Or even can’t get it 24/7 for the victim in need.