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CMAJ
CMAJ - June 27, 2000JAMC - le 27 juin 2000

Implementing public-access programs for automated external defibrillation

CMAJ 2000;162(13):1805-7

In response to: M. Shuster, W. Clark
We thank Michael Shuster and Wes Clark for their comments about our article [Research].1 Unfortunately, we find no firm basis for their enthusiasm. While we have noted that the use of automated external defibrillators (AEDs) by lay responders has the potential to increase survival after cardiac arrest, we do not agree that its effectiveness is no longer in doubt.

Only 5 studies, reporting outcomes for 154 patients, have been published on public-access AED programs.2,3 These were either case series or poor-quality cohort designs. At best, this would allow a grade C recommendation based on level 4 evidence.4 Furthermore, all programs required medical supervision and used trained lay responders who were otherwise expected to take command during an emergency (e.g., security guards, flight attendants). There is no report that describes AED use by the unsupervised public, and concern has recently been expressed that in some settings, a worse outcome may result.5

It is worrisome that an organization such as the Heart and Stroke Foundation would use a personal communication (in this case, a personal email message) from the College of Physicians and Surgeons of Ontario as a de facto means to declare that the use of an AED by lay people is no longer a controlled act in Ontario. Defibrillation is considered by the Regulated Health Professions Act (1991) of Ontario to be a controlled act requiring direct physician delegation. Policy I-99 of the College of Physicians and Surgeons of Ontario indicates that "at all times, accountability and responsibility for the delegation of a controlled act remains with the delegating physician."6 The subsection of the Regulated Health Professions Act quoted by the College representative indicates that the restriction against performing controlled acts "does not apply with respect to anything done by a person in the course of rendering first aid or temporary assistance in an emergency." We are unaware of any public direction given to Ontario's physicians by the College regarding the obvious dilemma caused by this contradiction. Public clarification by the College is urgently required.

While public-access AED programs may not require direct physician delegation, we believe physician supervision is vital in establishing medically sound defibrillation protocols, transfer of patient care, preservation of clinical data and continuous quality improvement programs. This is unlikely to be achieved in an unregulated environment.

We are not reassured that grade 6 students can learn to give a single shock using an AED on a mannequin. It is inappropriate to extrapolate their success to situations in which adults are using an AED during a cardiac arrest in a public setting, which are infinitely more complicated and chaotic. Other research has shown that layperson training results in disappointing AED competency after 1 year7 and that cardiopulmonary resuscitation performed by bystanders, in addition to early defibrillation, is essential if survival rates are to be improved.8

Given the potential for public-access AED programs to save lives, we cautiously embrace their promotion, but not in the way outlined by the Heart and Stroke Foundation. We believe these programs must be implemented under the supervision of responsible medical personnel to ensure integration with emergency medical service responders (e.g., paramedics, firefighters, police), who ultimately become responsible for every patient treated under a public-access AED program. Only then can the public be assured that AED use by lay people is safe and effective.

Richard Verbeek
Brian Schwartz
Sunnybrook and Women's College Health Sciences Centre
Toronto, Ont.

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References
  1. Schwartz B, Verbeek PR. Automated external defibrillation: Is survival only a shock away? CMAJ 2000;162(4):533-4. [MEDLINE]
  2. Kern KB. Public access defibrillation: a review. Heart 1998;80:402-4. [MEDLINE]
  3. Valenzuela T, Bjerke HS, Clarke LL, Hardman R, Spaite DW, Nichol G. Rapid defibrillation by nontraditional responders: the casino project. Acad Emerg Med 1998;4:414-5.
  4. Cook DJ, Guyatt GH, Laupacis A, Sackett DL, Goldberg RJ. Clinical recommendations using levels of evidence for antithrombotic agents. Chest 1995;108 (4 Suppl):227S-30S.
  5. Ornato JP, Hankins DG. Public-access defibrillation. Prehospital Emerg Care 1999;2:297-302.
  6. College of Physicians and Surgeons of Ontario. The delegation of controlled acts [policy statement]. Toronto: The College; 1999. Available: www.cpso.on.ca/faqanswer.asp?FAQNum=18 (accessed 2000 May 30).
  7. Asplin BR, Mosesso VN, Lejeune D. Evaluation of layperson competency and skill retention in the use of automated external defibrillators. Acad Emerg Med 1998;5:414.
  8. Stiell IG, Wells GA, DeMaio VJ, Spaite DW, Field BJ, Munkley DP, et al. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ann Emerg Med 1999;33:44-50. [MEDLINE]

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