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Use of Automated External Defibrillators in Cardiac Arrest
OHTAC Recommendation
Use of Automated External Defibrillators in Cardiac
Arrest
December 16, 2005
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Use of Automated External Defibrillators in Cardiac Arrest
The Ontario Health Technology Advisory Committee (OHTAC) met on
December 16, 2005 and reviewed a health technology policy assessment
of the use of automated external defibrillators in the initial management
of cardiac arrest patients presented by the Medical Advisory Secretariat.
Survival in cardiac arrest patients is low – approximately 5% in out-ofhospital settings and 10-20% in hospital settings. Early defibrillation has
been shown to improve the survival rate in cardiac arrest patients,
especially when delivered within 8 minutes from the onset of the cardiac
arrest. However, in out-of-hospital settings and in certain areas within a
hospital, trained personnel and their equipment may not be available
within 8 minutes. This implies that ‘first responders’ should take up the
responsibility of delivering the shock. The first responders in out-ofhospital settings are usually bystanders, fire fighters, police and
community volunteers, and in hospital settings, they are usually nurses.
Most of these first responders are not trained in reading
electrocardiograms, identifying shockable heart rhythms and operating
defibrillators.
The automated external defibrillator (AED) is a device that can be used by
first responders to analyze a heart rhythm and deliver a shock if needed.
AEDs have a role in strengthening the ‘chain of survival’ which includes
prompt activation of the 911 telephone system, early cardiopulmonary
resuscitation (CPR), rapid defibrillation, and timely advanced life support.
In out-of-hospital settings, the emergency response system consists of a
911 telephone call system linked to fire-fighters, police and ambulance
services. Almost all fire-engines are equipped with AEDs. Approximately
30% of police responders carry AEDs. All ambulances are equipped with
defibrillators. The standard target is to reach the site of arrest with a
defibrillator within 8 minutes of receiving the call for 90% of the total
calls.
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Use of Automated External Defibrillators in Cardiac Arrest
In hospital settings, the emergency response system typically comprises
of a ‘code blue’ system. A code blue team which is trained in CPR,
defibrillation and advanced life support takes over the management of
the cardiac arrest patient from first response staff once they arrive. The
standard target is to reach the patient with a defibrillator within 3
minutes.
Whether the arrest occurs in an out-of-hospital setting or in hospital,
following initial resuscitation, the patient is transferred to an intensive
care unit for further management.
During the 37th Parliament, Second Session, in 2001, a private members
public bill, Bill 51, Portable Heart Defibrillator Act, 2001, (an act to help
save lives of Ontarians who suffer from cardiac arrest by promoting the
widespread availability and use of portable heart defibrillators in public
places), was referred to the Standing Committee on Justice and Social
Policy, debated, and defeated. The Bill would have made provision of
AEDs mandatory in significant public buildings, including privately
owned buildings, such as shopping centers, arenas, and stadiums that
have significant public access. The Bill would also have provided
protection from civil liability to users of defibrillators and owners of
premises in which the defibrillators were installed where the defibrillator
was used “on a victim of a perceived medical emergency in good faith
without gross negligence or reckless misconduct.”
In 2005, in the Report of the Office of the Auditor General of Ontario
regarding its value for money audit of Land Ambulance Services the
Auditor recommended that:
to help ensure that response times for emergencies, including
cardiac arrest, meet the needs of patients throughout the province,
the Ministry should assess the costs and benefits of a fully
coordinated emergency response system that includes strategically
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Use of Automated External Defibrillators in Cardiac Arrest
placed publicly accessible automatic external defibrillators.
(Government of Ontario Publication, Chapter 3.02, page 44).
The Ministry responded that at the completion of this review, commenced
in August 2005, OHTAC would make recommendations to the Deputy
Minister and the health care system on the settings in which AEDs are
cost effective.
Results of a health technology assessment conducted by the Medical
Advisory Secretariat (MAS) shows that the use of AEDs in a public access
defibrillation [PAD] program significantly improves survival rates, through
rapid defibrillation. PAD programs require installation of AEDs in public
access areas and training lay responders in CPR and AED use. Also
optimization of the emergency medical services (EMS) system significantly
improves survival rates. Training citizens in CPR with or without training
in the use of AED may further improve survival outcomes. However, in
Ontario most cardiac arrests (79%) occur at home – 56% in single
residential dwellings and 23% in multiple residential dwellings. Specific
predisposing risk factors for cardiac arrest are not precisely known –
although patients with a history of heart failure plus a left ventricular
ejection fraction < 35% form a ‘high risk’ group. These individuals might
also be candidates for implantable cardiac defibrillators (ICD).
The cost of an AED is in the range of $2,000-$4,000 and cost of CPR
training and the use of AED is in the range of $60-$160. AEDs last up to
five years and users need to undergo refresher training courses to retain
their skills. It is neither practical nor cost effective to deploy AEDs in all
homes. Similarly, it is not cost effective to deploy AEDs in public access
areas. For example, if AEDs are installed in 3,000 government buildings
in Ontario, one additional life may be saved annually. This corresponds to
$184,467 to $1.7 million per quality adjusted life year gained over a fiveyear period. However, AEDs would be cost effective in hospital settings
where cardiac arrest rate is high and in settings where there are
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Use of Automated External Defibrillators in Cardiac Arrest
individuals at ‘high risk’ of cardiac arrest. Unfortunately, the deployment
of AEDs for this ‘high risk’ group has not yet been studied, so that there
are no data to support the use of AEDs for such patients. However, the
use of AED and CPR in this group of patients could prevent sudden
cardiac deaths and is cost-effective. Given the important patient outcome
this is more than merely hypothesis seeking.
OHTAC Recommendations:
OHTAC recommended the following with regard to the use of automated
external defibrillators.
OHTAC endorses and supports the current policy of giving AEDs to
EMS, fire-fighters and police;
OHTAC does not recommend the installation of AEDs in public
buildings where the very low probability that an arrest would occur in
these buildings offsets the benefits;
OHTAC supports the provision of AEDs in those areas of the hospitals
which are not readily accessible by the code blue team;
OHTAC supports the current initiative taken by some airlines to place
AEDs on aircrafts and train flight attendants in CPR/AED use;
The use of AEDs in the homes of ‘high risk’ individuals who do not
have an ICD has not been studied. However, it is reasonable to
recommend access to AEDs to these patients, in the context of a
broader comprehensive response plan. To be effective, caregivers in
these settings would need to be trained in CPR and AED use to
ensure the value of having the AED available.
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