Monday, November 1, 1999

Automated External Defibrillators: In Recreation and Athletic Centers - Get Ready

Editors - Dr. Neil Dougherty & Diane Bonanno

The debate on whether automated external defibrillators (AED) should be used in recreation centers is currently underway nationally. It has been precipitated by the American Heart Association's (AHA) recommendations on "Public Access to Defibrillation" and the outcome of a recent lawsuit in Florida where the failure of a recreation facility to have an AED available in an emergency was a vital consideration in the jury's deliberation.

According to the AHA, automated external defibrillators should, at the minimum, be located in highly populated areas such as stadiums, malls, and office buildings, and places where emergency medical teams are not readily available such as airplanes, and large urban centers where traffic may play an important role in the response time of an emergency vehicle. If this occurs, they contend, almost 100,000 lives will be saved each year and many people agree. The growing acceptance of this idea is evident in a recent verdict that was brought against the Busch Entertainment Group and Busch Gardens Tampa Bay in a case involving a 13-year-old girl who collapsed and died after a roller coaster ride. One of the important factors in the jury finding for the plaintiff was the lack of an AED and trained personnel who could use it.

Acceptance is also growing in legislative circles around the country. In March of 1999 New Jersey became one of a growing number of states to pass a public law that set standards for the use of AEDs by individuals who were not medical people. Many believe laws of this kind will accelerate the adoption of AEDs in public places such as recreation centers, and that we are only a year or two away from AEDs becoming a recognized standard of care in these facilities. One contributing factor, of course, is that recreation centers are already required to have CPR trained staff in their fitness centers and pools because they are high-risk areas. It would require very little training beyond CPR to prepare a staff to properly use an AED.

While there is no way of accurately predicting whether a person may suffer a sudden cardiac arrest, we do know that everyone is vulnerable; even seemingly healthy young people who exercise regularly. We also know that the availability of an AED and someone trained in its use increases one's chances of surviving a potentially fatal heart attack if it occurs in our centers. In our view there is no more compelling argument for taking a proactive stance in this debate.

Approximately 250,000 people die each year of sudden cardiac arrest. The vast majority of these deaths occur outside of a hospital where first responders can pro- vide only CPR to the person in distress until an ambulance arrives. While CPR can keep oxygen flowing to the brain, it does not provide the electrical shock to the heart that is generally needed to save the individual's life. Only a defibrillator can do that and even then the defibrillator is only effective if it is used within a short 10-minute window following the incident.

Responding rapidly with electrical shock is essential when dealing with sudden cardiac arrest. Every minute that defibrillation is delayed the victim's chance of survival decreases by about ten percent. Until recently this was a problem. Because defibrillators were administered only by paramedics who were frequently the last ones on the scene in an emergency, an ambulance delayed in traffic for ten or twelve minutes could very well arrive too late to be of assistance.

Recent improvements in technology and statutory immunity have made it possible for first responders to provide what only medical personnel could do previously. The latest generation of automated external defibrillators are lightweight, affordable, easy to maintain, and most importantly, easy to use. With these new devices, personnel no longer have to be trained to interpret the electrical rhythm of a patient's heart before defibrillation is applied. The machine does it for the operator and cues the appropriate response. This, in conjunction with the civil liability immunity many states provide, makes it more likely that people who suffer a sudden cardiac arrest will receive the rapid care they need.

Making automated external defibrillators a part of the emergency action plans at gymnasiums and recreation centers will complete the American Heart Association's "Chain of Survival" which advocates:

(1) Early access to care through a system such as 911,
(2) Early cardiopulmonary resuscitation or CPR,
(3) Early access to defibrillation, and
(4) Early advanced care.

It is the last link in providing our clients with the best protection possible when it comes to sudden cardiac arrest.

In an effort to lay the groundwork for installing AEDs in any given recreation center or gymnasium one should consider the following critical questions:

•If AEDs are used, where should they be located?
•Who should be charged with the responsibility of using the AEDs in an emergency?
•Who should train and test personnel in the use of the AED?
•Who should supervise the program?
•Where should the AED be physically located in each facility?
•What is the chain of events in the emergency action plan for cardiac arrest?
•What are the start-up costs?
•What are the annual costs?
•What automated defibrillator should be selected?
•What is the timeline for start-up?

Locating the AEDs
The American Heart Association has suggested that automated external defibrillators be located:
•Wherever there are 1,000 or more people in a close area
•Where the likelihood of sudden cardiac arrest is increased because of the population in attendance
•Where emergency vehicles might have difficulty responding to a crisis in time to be of assistance, and
•Where the activity might increase a person's risk for cardiac arrest.

Because most recreation centers and athletic facilities attract I 000 or more people of varying ages and abilities to a variety of high risk activities throughout the course of a normal day's programming or during the progress of a special event, and because they are already required by industry standard to have personnel trained in CPR, these facilities are perfect sites for AEDs.

When considering the location of the AED one should give thought to the following:
Is there a location in your facility that is staffed the entire time that the building is open? In general the AED should be kept at a central location which is constantly staffed. Remember, how- ever, that for every one-minute delay the likelihood of survival decreases by ten percent and that defibrillation will most likely be needed in the aerobics room and at contests with a large number of spectators. The AED should not be under lock and key when the building is open.

Administrators may opt to locate the Automated External Defibrillators at the front desk, administrative center or nurse's office in each building. While these are not always the locations that are most centrally located, they appear to be the most logical place to store the AED.

• Each would normally be equipped with a communication device which means that it receives all of the emergency calls from the various rooms in the building.
• There should be a phone located at each site which can be used to call the police in an emergency.
• These sites are often staffed by more than one person which means that one could be called upon to deliver the AED to the emergency while someone else notifies the police.
• The people staffing these sites are usually an integral part of all of the emergency action plans.
• The AED can be moved rapidly to any location in a building.

If a special event is scheduled on out- door space the administrator and the Safety Committee can review the particulars of the event and determine whether an AED and a person trained to use it should be assigned to the event.

Develop a dialogue with outside groups that use your facility to determine how your AED units may or may not be used in conjunction with their emergency action plans for activities under their control.

Assigning Responsibility for AED Use
The number of people who are given the responsibility of using the AED in an emergency should be kept to a minimum. This will lessen confusion during the crisis and improve quality control overall. They should also be an integral part of the response team for all emergencies and have the necessary basic training in CPR.

Specific guidelines that could be considered in the selection of persons charged with the responsibility of using the AED include:

- A designated responder (DR) must be on duty in the buildings whenever the facilities are used.
- All DRs should hold current certifications in First Aid and CPR for the Professional Rescuer,
- DRs should be well trained in deploying the organization's emergency action plans.
- DRs should have experience handling emergencies and should be an integral part of every action plan.
- DRs should meet monthly to review their CPR skills.
- The pool of DRs should be kept very small to facilitate quality control.

Where there is a designated responder all other staff and administrative personnel should recognize and yield to their authority in an emergency.

While lifeguards may soon be required to learn to use an AED as part of their certification requirements, their role in a cardiac arrest emergency in the pool should remain that of the CPR provider. The primary responsibility of an AED responder should remain with the designated responder. The lifeguard should only be called upon to use an AED as a backup should the original action plan fail. To be sure that the lifeguard is prepared to act as a backup, their skills should be reviewed each month during their in-service training.

Training and Testing
Training and testing should be considered an essential part of the process of installing AEDs in any location. It is recommended that initial training be followed by a schedule of monthly testing and periodic retraining to be sure that the responder can perform the appropriate skills when needed.

There are several agencies that provide certification for AEDs. The choice is left to the discretion of the unit that intends to use the machine as a part of its action plan. Be sure to check your state laws for course requirements. New Jersey, for in- stance, requires that the course be found acceptable by the Department of Health and Senior Services.

The American Red Cross, The American Heart Association and the Safety Council all offer certification courses that cover the proper use of the Automated External Defibrillator, While they vary in length they basically cover the same material and are recognized by most authorities. Regardless of the program you decide to use you may wish to consider the following:
• It may be more convenient to secure AED training from the agency that provides your CPR training.
• Initially you will probably need to secure training from an outside agency or company.
• During the startup year, however, seriously consider having every member of the Safety Committee become certified instructors for the AED course you have adopted.

This will allow them to: (1) assist with the in-service training done by the certifying agency, (2) provide the monthly testing, and documentation of all personnel, and (3) assume the role of provider during the second year of operation.

- At the minimum, consider having your organization's Training Coordinator and the Risk Management Coordinator become certified to train AED instructors.

- Lifeguards, intramural supervisors, coaches and fitness assistants should be given the option of getting AED training after they have been trained in CPR for the Professional Rescuer and until such time as this training may become a standard of care for these positions.

- Although all personnel will not be required to become certified in the use of an AED, all staff training should contain a module on AEDs. The modules would include back- ground information on sudden cardiac arrest, the use of AEDs and the role AEDs will play in the organization's emergency action plans.

- Testing is one way of insuring that all personnel are performing their skills properly. It is also a method of helping staff members to feel more confident about their ability to de- liver assistance during an emergency. Every staff member charged with the primary responsibility of using an AED, should be tested by a member of the administrative cadre once a month and at least one of these testing periods should be the result of a surprise visit. If a staff member does not perform to the level expected by the tester, the individual should be required to schedule a private meeting with the tester to review their skills before they are scheduled to work their next shift.

- Copies of the certification cards and the records that verify monthly testing should be kept by: (1) the supervising physician, (2) the unit manager, and (3) the organization's Business Manager.

The Emergency Action Plan for Sudden Cardiac Arrest
There should be an emergency action plan for sudden cardiac arrest that: (I) requires staff members at the scene of the incident to notify the designated AED responder and to begin CPR, (2) designates who should notify emergency services and who should bring the AED to the emergency, and (3) identifies the AED responder and requires him or her to move to the scene of the emergency immediately.

General Program Supervision
An emergency response program that includes automated external defibrillators should and, in many states must, be supervised by a licensed physician. The physician would monitor the program, ensuring that the department or individual using the AED complies with all appropriate standards. This would include being sure that:
• all personnel have on record current certifications demonstrating that they have been trained in the proper use of an AED.
• the defibrillator is maintained and tested according to the manufacturer's specifications.
• the appropriate emergency service provider has been notified that the department has acquired an AED.

To facilitate program supervision, consider forming an Emergency Response Committee whose sole responsibility would be to take the actions necessary to insure that all provisions of the law are met and that the supervising physician is kept informed of all actions.

The Emergency Response Committee should consist of a representative of each of the high risk areas (i.e. outdoor recreation, fitness, aquatics) a representative of the facilities staff, the department's training coordinator and a senior administrator.

The chair of the committee should act as the department's office liaison with the supervising physician, local Emergency Ser- vices, and the training/certifying organization. It would be the chair's responsibility to ensure that all sections of the law are met and to provide the supervising physician with all the necessary documentation.

The chair should provide the supervising physician with (1) copies of all current certifications, (2) the minutes of all Emergency Response Committee meetings, (3) verification of all testing, (4) all maintenance and repair records for the AEDs, and (4) recommendations for any change in policy or procedures.

© Copyright School and Community Safety Society of America, November 1999, Volume 4, No. 2.

Department of Exercise Science & Sport Studies
Rutgers University
Loree Gymansium
70 Lipman Drive
New Brunswick, NJ  08901-8525
(732) 932-8673  -  FAX (732) 932-9151

Diane Bonanno
Rutgers University
Loree Gymansium
70 Lipman Drive
New Brunswick, NJ  08901-8525
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PO Box 767
Northport, NY 11768
Phone: 631-754-1091