Public Access Defibrillation: Establishing an Institution-Wide Program

• By Cmdr. Shad U. Ahmed
• 11/01/09

Semi-automated external defibrillators (AEDs) are devices that can deliver a life-saving electric shock to a heart in the event of sudden cardiac arrest (SCA), when the heart suddenly stops.

AEDs have become so commonplace that the public expects access to the devices in most places. In fact, laws, regulations, or other legislation may eventually require the placement of these devices at specific locations, such as health clubs, medical facilities, schools, athletic events, etc. That expectation can extend to colleges and universities, and administrators cannot afford to neglect implementing an integrated, comprehensive, campus-wide program that encompasses everything such as purchase, placement, training, communications, documentation, maintenance, and upgrades.
 
Campus-Wide Programs: All On Board
On the liability front, if an AED is not placed where it would be prudent, installed devices are not properly maintained, personnel are untrained, or the devices are not accessible, the institution could face serious and costly litigation. Individual departments would generally not be responsible for defending the institution, therefore the institution must assert campus-wide responsibility and centralize this type of program. Let’s take a look at a few common liability myths to understand the necessity of a comprehensive program.
 
Dispelling Common Liability Myths

• “Having an AED is a liability in and of itself. If we cannot properly maintain an AED, we should just not have one.” A common myth is that AED use would add to the liability the institution takes on. Further, some believe that if an AED cannot be properly maintained, then it should be removed. On the contrary, the absence of an AED can itself be a liability when “industry standards” or “what can be reasonably expected” may call for it. That’s the lesson learned by a health club in Gaithersburg, MD, where an AED was not available after a man collapsed from SCA.
• “An AED should be used only by trained personnel. Therefore, it should be locked away when the EMTs, medical staff, nurses, or trained responders are not in the building.” That’s what one school system in Naples, FL, thought, until a lawsuit was filed because of an incident that revealed that an AED was locked in the nurse’s office after-hours and wasn’t available to save a victim of SCA during a basketball game. The suit further stated that AEDs were not placed where SCA was most likely to occur. Many “lay rescuers” (people without any other medical education) are trained in the use of AEDs, so they should remain accessible, easily identified, and located.
• “It’s better to wait for the paramedics to arrive to care properly for the patient.” SCA is a killer, and research shows that the first three to five minutes after collapse is the ideal time for the maximum efficacy of shock. The American Heart Association says the chance of survival decreases seven to 10 percent with each passing minute. The time it takes from noticing someone collapsing to calling 911 to routing the call properly to dispatching the ambulance, and then for the ambulance crew to gear up, drive to the scene, get out, assess the situation, and treat is often far longer than it would take someone to locate and use an AED. The ambulance crew can take over upon their arrival.
• “AED training for students and staff would place us at greater risk, and it increases the liability for the institution in case they make a mistake.” Almost every state has what are commonly referred to as Good Samaritan laws. Collectively, these laws provide for the protection against civil damages for lay rescuers performing CPR, AED, or other lifesaving techniques in a good faith effort. A qualifying condition that requires the individual to be properly trained to some national standard is also typical, but a good faith effort is still the key guideline. Some states, such as Rhode Island, further protect the trainers, the organizations where devices are placed, the owners of the devices, and the property owners where devices are placed.
• “If CPR/AED cards for the staff are expired, they are not permitted to perform CPR or use the AED, and we should prohibit them from doing so.” CPR “certifications” hold no legal standing as a license to practice or perform. Rather, they are training guidelines and recommendations. While it would be prudent for an institution to mandate current training and certification, an institution should not prevent an employee or bystander from performing CPR simply due to a date on a card. Life safety is the number one priority.

 
Developing the Program
Now that it is clear that AEDs and a comprehensive program to support the devices are important, let’s look at the development of such a program. The first step is to bring together a team that could positively contribute to the development and maintenance of such a program. This team can serve as an advisory support group and should include representatives from campus and local departments, including public safety/police/security, health service/health clinic, legal counsel, EMS, and fire departments. This team may not have formal authority, but can serve as a forum for broad discussion. Topics such as current programs, devices, procedures, and more should be discussed.
 
Program Oversight
The first real task is appointment of administrative and medical program oversight. This is the core group of people with formal campus-wide authority to implement and enforce the program guidelines.

• Program Medical Director. While the use of an AED does not require medical education, they can only be purchased with physician authorization. Further, a physician with advanced training can better monitor their use for quality assurance purposes. Therefore, the first designation should be for Program Medical Director. This individual would direct all medical procedures, review policies, participate in post-incident debriefings, and provide QA/QI support.
• Program Administrator/Coordinator. This designee would be the authority for all administrative actions for the program and would be responsible for program approvals, policy/procedure updates and enforcement, liaison to vendors, etc. This person would preferably have knowledge of AED operations and should remain up-to-date on research data, use, and guidelines.
• Program Training Coordinator. This individual would be charged with coordinating, documenting, and support for CPR/AED training. This individual will reach out to training centers if they are not on campus and connect with instructors to ensure that adequate and up-to-date training is available and can be supported. All staff persons who are trained under this program should be documented and kept on file. This person would also be responsible for maintaining training equipment if appropriate.
• Site Coordinators. Depending on the size, complexity, and organization of the institution, it may be appropriate to also have site coordinators assigned to some or all buildings, regions, departments, satellite campuses, etc. These individuals would be the primary liaisons for their specific sites and would ensure compliance to the institution-wide program, coordinate maintenance or inspection checks as required by the program, etc.

 
Device Selection
Institution-wide standardization of device model/type will simplify training and streamline the rest of the program. Therefore, the institution should look closely at the different options available and discuss them with the program medical director. It may also be cost-effective in the long term to select one or two devices for the institution. An institution may want to select two levels: one for the public, and an advanced version for medical or other trained staff that would allow more function (such as manual override). A quick phone call to the campus or local EMS squad, fire department, and hospital will determine the models they use.

Choosing a similar model or stocking a pad adapter with each model will decrease the times that either the pads need to be pulled off for other equipment to be attached, or that your AED unit would need to be transported with the patient. Most AEDs all perform similarly, but there are advanced features now available such as CPR feedback that tells you if your CPR is effective (most CPR provided is not) and how to correct it, etc. The FDA can provide information on recalls or warnings provided to manufacturers that may also help.
 
Device Placement
When considering where to install AEDs, the institution should look first at public venues, athletic and recreational facilities, and “high risk” or “high volume” areas. The American Heart Association recommends that AEDs be placed strategically at points throughout such venues that would provide a three-minute “collapse to rescue” time, meaning the time it takes to retrieve an AED to a patient that has collapsed.

Public venues especially should consider using signed and visible AED cabinets. For little additional cost, cabinets can be alarmed, and even tied into the telecom infrastructure to notify your public safety staff/dispatchers. A written policy should direct the dispatcher to dispatch public safety/security/police and the campus or local EMS upon activation of an AED alarm.
 
Public Education
Just placing the devices is not enough. It would be prudent to identify and publicize the locations of the AEDs. Public venues should be signed, and all maps of facilities and campuses should identify locations of AEDs. This is so visitors can easily identify where devices are located if the devices are ever needed. With so much competition for so-called “real estate space” on these maps, it is important to understand that prioritizing this is imperative for obvious life safety and other reasons. Further, during orientations, fairs, and other events, public safety and health or other staff could further raise awareness of the devices and available training.
 
Training
The institution must offer CPR/AED training to faculty, staff, and students. This can be done quite easily through the public health, EMS, or similar function on campus, or through a local community partner. The training must be authorized by and follow a national standardized curriculum, since most Good Samaritan laws protect on condition of those standards for training. The added value of easy access, cost-effective, and national recognition make those trainings ideal. The training coordinator should ensure key people are trained and that training remains up-to-date. Key personnel include all public health function staff, public safety responders, building managers, key administrative personnel, resident assistants, etc. RAs would make ideal persons to train, since most students reach out to these individuals first in an emergency.
 
Maintenance and Upkeep
It may well be worth considering a maintenance contract for your institution. The costs can be distributed among departments. Depending on the number of units, it may easily make up for the disposable costs associated with keeping up with the devices individually. A good contract will be completely hands-off and cover replacement of all parts and labor for everything, such as:

• Incident and test data download from AED
• Test load to verify all functions (not just a self test)
• Full visual inspection of all connectors, batteries, accessories, cases, etc.
• Service hardware and software upgrades
• Replacement of all parts and disposables as needed, usually before the expiration
• Loaner unit if unit needs to be taken out of service

 
Some contracts will even offer a technician to come out after each use and replace all parts and perform a full test. The bottom line is that under a decent contract, the institution shouldn’t need to pay a dime outside of the contract cost. It is recommended to have a contract that brings a technician out at least once per year to conduct a full test of each unit. Simple monthly inspections with minimal training (ten minutes or less) can be done by the site coordinators or other designated staff. This could potentially equal or come near the cost of replacing all disposables alone over time for each unit, and far outweigh the cost of potential negligence litigation after an incident.
 
SCA Incident With AED Utilization
Policies should be clear as to what is advised during an SCA incident where an AED is available, and they should follow national guidelines. For example, activating EMS early on may be advised, and therefore an institution should not recommend that a supervisor or manager be first located. During the incident, a seamless transfer of care to higher trained medical staff and EMS should be planned for. All pertinent information related to the incident should be reported to them.
 
Post Incident
After an incident, a post-incident debriefing should be mandated. Even first responders are often required or strongly recommended to attend critical incident stress debriefings (CISD) for serious incidents. An SCA incident could have potential psychological effects, and the institution should ensure that proper care is offered. This can be pre-arranged with the institution’s counseling services. Full documentation of the incident should also be provided to the program administrator and the program medical director for a review. Program leadership should also be involved in the debriefings.
 
Program Manual and Policies
However the institution tackles an AED program, it should be well documented, and all policies covering the above topics need to be written out. There should be no question as to what is expected of each person involved and also for the procedures for using and maintaining an AED. The Program Manual should also have relevant appendices, indicating contact persons, any records and documentation requirements and forms (for monthly checks, use of an AED, maintenance, etc), institution-approved or authorized devices, how to purchase, and available optional equipment/training/service options to individual sites.
 
Review
The final aspect of a comprehensive program is perhaps the most important. Continuous QA/QI and administrative review is the key to keeping up with changing dynamics. The Program Manual and all its components need to be relevant, and should be updated as often as needed with at least one annual full review.
 
Putting It All Together
The legal question of whether the institution has done all that it could be reasonably expected to do has a multifaceted answer. Whether devices exist where SCA is at risk to occur, whether they are properly maintained, staff training, identification, and public education will all come into question if an incident occurs. Rest assured, an incident will occur, and the institution should be ready. Implementing a comprehensive, integrated campus-wide program as specified here is a step in the right direction.
 
Cmdr. Shad U. Ahmed is the Director of the National Institute for Public Safety Research and Training and Chief of Emergency Medical Services at the University of Rhode Island. He is the Principal Investigator on a Homeland Security project developing a national training curriculum for colleges and universities in emergency planning and mass evacuation. Cmdr. Ahmed may be reached at [email protected].