Considerations in purchasing a defibrillator First Aid and Medical Equipment Section: Defibrillator Group
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Introduction
Purchasing a defibrillator (also commonly called an Automated external defibrillator or AED) for lay person use is a very important step in protecting your staff, guests, contractors or community from out of hospital cardiac arrest (OHCA). Sudden cardiac arrest is a major cause of death in all developed western countries. In Europe, around 1 in 1,000 of the population suffers sudden cardiac arrest each year, so in the UK there are likely to be approximately 60,000 cases annually. In England, the ambulance service attempt resuscitation in approximately 25,000 cases per annum but at present, only a small proportion survive.1
Automated external defibrillators (AEDS) are designed specifically for lay persons to use. Early defibrillation, as part of the Chain of Survival is an important step in resuscitation of a sudden cardiac arrest victim. Early defibrillation is the only effective therapy in correcting a lifethreatening cardiac arrhythmia. A strong Chain of Survival can improve chances of survival and recovery for victims of sudden cardiac arrest. The four links in the adult Chain of Survival are: • Immediate recognition of sudden cardiac arrest and activation of the emergency response system.
A sudden cardiac arrest can affect anyone, at any age, at any time.
• Early CPR with an emphasis on chest compressions.
The major reason for the high number of deaths worldwide from sudden cardiac arrest is the delay in getting a defibrillator to the scene. The sooner a victim of sudden cardiac arrest is defibrillated the higher the chance of survival. Relying on the ambulance service to reach the scene of the incident quickly enough is not an option. Ideally the first defibrillatory ‘shock’ should be delivered in 3-5 minutes.
• Early defibrillation.
A victim’s chance of survival decreases by 7 to 10 percent for every minute that passes without defibrillation.2
• Effective advanced life support. Placing a defibrillator(s) in your workplace, community or similar environment will give staff, visitors, contractors, guests and your local community reassurance that a life-threatening event can be responded to quickly and efficiently while professional medical services are en-route.
1 A guide to Automated External Defibrillators (AEDs); UK Resuscitation Council December 2019 https://www. resus.org.uk/ publications/a-guide-to-aeds/ 2 Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102 (supplement I) 8. August 22, 2000.
Considerations in purchasing a defibrillator
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Signs of Sudden Cardiac Arrest
A sudden cardiac arrest occurs when the heart stops functioning normally due to the irregular and chaotic passage of cardiac impulses throughout the heart (an ‘electrical’ problem). A heart attack is caused by a blockage in the coronary arteries which impedes blood flow and thus oxygenation of the heart muscle (a ‘plumbing’ problem).
A person is deemed to be suffering a sudden cardiac arrest if they are: • unresponsive • not breathing normally Current resuscitation guidelines, published in 2015 by the European Resuscitation Council (ERC) and American Heart Association (AHA) and endorsed by the UK Resuscitation Council, provide guidance on the protocol for dealing with a sudden cardiac arrest (see flow chart, Appendix 1). A sudden cardiac arrest is not the same as a heart attack; these two conditions are treated entirely differently.
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Considerations in purchasing a defibrillator
A defibrillator is designed to only treat sudden cardiac arrest and provides a direct current electrical ‘shock’ in order to momentarily stop all electrical activity in the heart cells allowing the natural ‘pacemaker’ cells to operate normally.
What is an AED?
Specifically designed for use by lay persons, an AED is a defibrillator that uses step by step audible voice prompts (some devices also have visual prompts on an integral text screen). The device gives instructions for how to place two adhesive pads on the victim’s chest, through which the AED will analyse the victim’s heart rhythm and, if the victim is in sudden cardiac arrest, use its battery power to automatically deliver a direct current ‘shock’ to the heart, through the pads. This process will momentarily stop all electrical activity in the heart cells to allow the heart’s pacemaker cells to operate normally. This process is called “defibrillation”. AEDs are available either in semi-automatic mode, which entails the rescuer pushing a ‘shock’ button when instructed to do so, or in automatic mode where the shock is delivered by the AED without rescuer intervention. The defibrillator will only deliver a ‘shock’ if the victim is in sudden cardiac arrest and thus is ideal for lay persons to operate safely and effectively.
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Defibrillation for a child
Paediatric electrodes, or a device containing a ‘switch’ which allows the rescuer to ‘toggle’ between adult and child settings, should be used for defibrillation of children between 1 and 8 years. When these electrodes are not available, an AED with standard electrodes should be used. Use of an AED is not recommended for defibrillation of children below 1 year of age.
Adult Pad Placement and Ped Pad Placement.
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Considerations in purchasing a defibrillator
Training requirements
As well as having a defibrillator on site it is also vital that as many people as possible learn basic skills in cardiopulmonary resuscitation. This entails recognising that someone may have suffered sudden cardiac arrest, calling the emergency services (999 or 112), and then performing chest compressions and rescue breaths. This basic first aid will maintain an oxygen supply to the brain and other organs and make it more likely that the heart can be restarted by defibrillation. The priority in the early stages is to provide chest compressions, and if a rescuer is unable or unwilling to provide rescue breaths uninterrupted chest compressions should be given. It is desirable for people to receive training in the use of the defibrillator and receive regular refresher training, as this will give them confidence to use one. At the time of an event a trained operator may not be available, but if this situation does occur there should be no restrictions on anyone else using the defibrillator. Indeed, the Resuscitation Council (UK) state, inter alia, that: ‘…… the use of AEDs should NOT be restricted to trained personnel. Furthermore, the Resuscitation Council (UK) considers that it is inappropriate to display notices to the effect that only trained personnel should use the devices, or to restrict their use in other ways’.3
This confirms similar advice from the British Heart Foundation. There are no legal barriers to anyone purchasing a defibrillator, or using one in the case of sudden cardiac arrest in the UK. Nobody to date has been successfully prosecuted for using first aid to assist a person in need. Further advice on the legal situation in the UK can be found on the Resuscitation Council (UK) website.4
3 Statement on the training required to use an AED; UK Resuscitation Council, April 2007, revised 2009 https:// resus.org.uk/defibrillators/ training-required-to-use-anaed/ 4 www.resus.org.uk/cpr/ legal-status-of-thoseattempting-cpr
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Key steps to implementing a defibrillator programme
Purchasing a Defibrillator
There are many different brands of defibrillators available for purchase by lay persons. While they will all defibrillate in the case of sudden cardiac arrest, the features and functions vary. In general a defibrillator should be: • easy to use. • able to carry out self-tests on the major elements of the device: pads, battery and internal software/components. This ensures they are always ready for use. (All lay person defibrillators carry out some form of self-testing which means the device requires minimal maintenance by the purchaser.) • placed in a suitable, unobstructed and visible location with appropriate storage and clear signage (see below). • where appropriate have a suitable carry case, spare pads (either adult pads or paediatric pads depending on the environment in which the defibrillator is placed), and a prep • kit containing appropriate items to assist in the SCA event. It is also important to purchase the appropriate quantity of devices for your location (see below).
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Considerations in purchasing a defibrillator
Site survey / location of defibrillators
A site survey should be undertaken to determine the number of defibrillators needed, and where they should be placed, to achieve the objective of responding to a sudden cardiac arrest and delivering the first ‘shock’ within three to five minutes. Factors such as the number of floors or spread of the site will need consideration. Some defibrillator manufacturers will assist the site staff in carrying out a site survey. Visible locations should be chosen which are clear to all employees / residents / visitors, unimpeded by any obstacles. Under no circumstances should the device be placed in a locked room as this could potentially cause a delay when the defibrillator is required.
Storage
A cabinet or housing should be purchased that is appropriate for the location and whether the defibrillator is to be placed inside a building or outside. Specially manufactured defibrillator cabinets should be used for storage indoors or outdoors, or a wall sleeve/bracket for indoor storage. (In some locations that are part of a Community Public Access Defibrillation Programme (CPAD) the ambulance service may wish to stipulate both the type and manufacture of the defibrillator and the specific type of storage facility.) Choosing a storage cabinet for a defibrillator will be determined by a number of factors such as whether it is to be sited outdoors or indoors, is to be locked or unlocked, heated or unheated, come with or without an alarm or a combination of all these features. Cabinets also come in metal, stainless steel or polycarbonate. Heated cabinets are required for outside installations to keep the device, battery and pads at an ambient temperature and to ensure full operational reliability when required. When installing a cabinet with heating the manufacturer’s instructions and any statutory requirements must be followed. Permission may need to be sought from the local Council or owner of the property, especially if placed outside. External location of defibrillator equipment is preferred so the device is available 24 hours a day, 7 days a week.
In respect of considering whether the cabinet should be locked or unlocked, the advice from both the Resuscitation Council UK and British Heart Foundation is to have unlocked cabinets so that there is no delay in retrieving the device in the case of a sudden cardiac arrest. Where a locked cabinet is chosen, the code to unlock the cabinet must be shared with the local ambulance service (see below) so anyone calling 999 in the event of a sudden cardiac arrest can get access to the defibrillator immediately. For further information see BHTA advice on a ‘Minimum Specification for a Defibrillator Cabinet’.5
Signage
Clear signage should be placed by the installation and to give direction to it from other points on site. The Resuscitation Council (UK) and British Heart Foundation have developed new signage for this purpose. There are several other options relating to signage available.
Operational protocol
Once a defibrillator is installed it is important to inform all employees. It is advisable to have a short product familiarisation training session to ensure employees are aware of the equipment, its features, and how to use it should a sudden cardiac arrest arise. In larger
5 http://www.bhta.com/ wp-content/uploads/2020/07/ BHTA-Defib-A4-2pp-v7.pdf
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Key steps to implementing a defibrillator programme
In 2019, the BHF and Microsoft, working with the UK ambulance services, introduced the Circuit. This is intended to be a UK-wide database indicating the location of all publicly placed defibrillators. This system will be available to all UK ambulance services in order to assist 999 callers being directed to their nearest defibrillator in case of a sudden cardiac arrest.
6 The Circuit https://www. thecircuit.uk/
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organisations an operational protocol may be introduced. Each organisation/ community should have a nominated person responsible for the defibrillation programme within their location.
At the date of this publication, the system has been piloted in the Scottish Ambulance Service and West Midlands Ambulance Service and will be rolled out across the rest of the UK. There are also a number of stand-alone systems that ambulance services currently use for this purpose. The objective of the Circuit is to link a UK-wide network of defibrillators to every ambulance service in the country and the public in a bid to help save more lives from sudden cardiac arrest.6
Working with your local ambulance service
Clinical audit
As the main NHS organisation responsible for out of hospital medical response the ambulance service should be informed of the placement of defibrillators in the community/public place. This enables them to record the location and access details of each defibrillator in their database so callers can be directed to the nearest device. Some ambulance services will provide advice and support to local defibrillator providers.
Considerations in purchasing a defibrillator
All defibrillators manufactured for lay rescuers have the capability for downloading information from the device memory. This information will include the victim’s ECG, time elapsed from start of rescue, error reporting, number of shocks delivered etc. This information is important for ambulance services and hospitals in determining ongoing treatment of a sudden cardiac arrest survival victim as well as being useful for compiling statistics around sudden cardiac arrest. As different
defibrillators use varying methods to download the information advice should be sought from the appropriate manufacturer.
Post rescue support
Dealing with a sudden cardiac arrest can be a very traumatic situation, especially for lay rescuers. It is important that the scheme’s nominated person and/or the local ambulance service have provision in place for adequate psychological follow up for rescuers involved in a sudden cardiac arrest incident, both where the victim survived or not. This may also be offered to the immediate family of sudden cardiac arrest victims. It is of the utmost importance that any post-rescue discussion takes place in a quiet area with no interruptions and on a strictly confidential basis. The rescuer and/or immediate family must be able to express their feelings freely and without criticism. Once the defibrillator has been used the nominated person must ensure the device is ready for use again as soon after the event as possible.
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Myth Busters
There are a number of myths around the use of defibrillators for lay persons. This can lead to a lack of confidence or a delay in the device being used during a Sudden Cardiac Arrest (SCA). The most common myths around the use of a defibrillator are: Ambulance response times Calls from people with life-threatening illnesses or injuries (Category 1 calls) include SCA and the current response times are as recorded by the NHS AQI Statistical Note, 14 November 2019, which states inter alia: ‘...The mean average C1 response time across England was 7 minutes 25 seconds in October…’.7 Given that a victim’s chance of survival decreases by 7 to 10 percent for every minute that passes without defibrillation the option of waiting for the ambulance service to arrive is not viable in terms of ultimate patient survival.
7 AQI Statistical Note, 14 November 2019 https://www. england.nhs.uk/statistics/ statistical-work-areasambulance-quality-indicators/
Training required to use a defibrillator Defibrillators designed for use by lay persons are safe, effective and easy to use. The defibrillator guides the user through the rescue process by means of audible voice prompts and there is no requirement, legal or otherwise for a lay person to be trained in its use.
8 Hands-On Defibrillation: An Analysis of Current Flow Through Rescuers in Contact With Patients During Biphasic External Defibrillation; Michael S Lloyd, Eric L Krivitsky, Paul F Walter, Jonathan J Langberg, Emory Univ, Atlanta GA
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Considerations in purchasing a defibrillator
SCA only happens to older, unfit, unwell people One popular myth is that only older, unfit and unwell people suffer a SCA. An SCA can happen to anyone of any age, including children and younger adults. A defibrillator can be used across the age range, with the exception of children under one year old. Maintenance needed on AEDs Due to the ability of lay person defibrillators to carry out regular automatic self-testing these devices require minimal maintenance (further advice on this can be found in the appropriate manufacturer’s manual). Rescuers/bystanders can be harmed by residual ‘shock’ from the defibrillator Lay persons have concerns about receiving a ‘shock’ from the defibrillator if they, or a bystander, are touching the patient during delivery of therapy. A lay person defibrillator utilises adhesive pads which deliver the shock to the patient. The majority of the current delivered goes into the patient’s chest and heart and current ‘leakage’ is minimal. One study showed ‘…..measured values were well below 2,500 microamperes, an accepted safety standard for earth-leakage current in medical devices……’.8
Glossary
AED Automated External Defibrillator.
OHCA Out of Hospital Cardiac Arrest.
Arrhythmia A condition in which the heart beats with an irregular or abnormal rhythm.
Paediatric Defibrillation The process of delivering defibrillation to a child up to eight years of age or weighing less than 25Kg.
BHF British Heart Foundation. Chain of Survival A series of actions that, properly executed, reduce the mortality associated with cardiac arrest. CPR Cardio Pulmonary Resuscitation. Defibrillator A device used to control heart fibrillation by application of an electric current to the heart.
SCA Sudden Cardiac Arrest. A condition in which the heart suddenly and unexpectedly stops beating. Blood stops flowing to the brain and other vital organs. SCA usually causes death if it’s not treated within minutes. Site Survey A method of determining the number and placement of defibrillators in a given location.
Defibrillation The stopping of fibrillation of the heart by administering a controlled electric shock, to allow restoration of a normal rhythm. ERC European Resuscitation Council. Heart Attack A sudden occurrence of coronary thrombosis, typically resulting in the death of part of a heart muscle.
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Appendix 1
Protocol for using an AED in the case of sudden cardiac arrest European resuscitation guidelines 2015 AED Algorithm
Unresponsive Call for help Open airway Not breathing normally Send or go for AED Call 999
CPR 30:2 Until AED is attached
AED assesses rhythm Shock Advised
No shock Advised
1 Shock 150-360 J biphasic or 360 J monophasic
Immediately resume CPR 30:2 for 2 mins
Immediately resume CPR 30:2 for 2 mins
Continue until patient starts to breathe normally 12
Considerations in purchasing a defibrillator
Considerations in purchasing a defibrillator
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