Integrating a PAD program in your facility's emergency response policy

A PAD program uses AEDs, which are sophisticated computerized machines that are simple to operate and enable a layperson with minimal training to administer this potentially lifesaving intervention. AEDs allow a layperson responding to an emergency to use the AED device, which can detect certain life-threatening cardiac arrhythmias and then administer an electrical shock that can restore the normal sinus rhythm. AEDs are the third step in the American Heart Association's (AHA's) renowned Chain of Survival concept, after alerting EMS and administering CPR. Helpful suggestions concerning the important features of PAD programs and resources to assist facilities with integrating the PAD program in their emergency response protocols may be found at the AHA website at www.americanheart.org.

Research reviewed by the AHA shows that the delivery speed of defibrillation, as offered by an AED, is the major determinant of success in resuscitative attempts for ventricular fibrillation (VF) cardiac arrest (the most common type of cardiac arrest). Survival rates after VF decrease 7% to 10% with every minute of delay in initiating defibrillation. A survival rate as high as 90% has been reported when defibrillation is administered within the first minute of cardiac arrest, but survival decreases to 50% at 5 minutes, 30% at 7 minutes, 10% at 9 to 11 minutes, and 2% to 5% after 12 minutes.

Communities that have incorporated AED use in their emergency practices have shown significant improvements in survival rates for individuals who have experienced cardiac events. For example, in the state of Washington, the survival rate increased from 7% to 26%; in Iowa, the survival rate increased from 3% to 19%. Some public programs have reported survival rates as high as 49% when an AED is used promptly. The American Heart Association is a strong proponent of having AEDs as accessible to the public as possible. The use and application of AEDs in a public setting are detailed in the American Heart Association's 2010 Guidelines for CPR and ECC.

Some key elements of an effective PAD program are as follows:

• Every site with an AED should strive to get the response time from collapse caused by cardiac arrest to defibrillation to four minutes or less.
• The Food and Drug Administration (FDA) requires that a physician prescribe an AED before it can be purchased. The AHA strongly recommends that a physician, licensed to practice medicine in the community in which the health/fitness facility is located, should provide the oversight of the facility's emergency response system and AEDs. In most cases, the company from which an AED is purchased will assist the facility with identifying a physician to provide these services. Physician oversight refers to the following:
  • Prescribing the AED
  • Reviewing and signing off on the emergency plan
  • Witnessing at least one rehearsal of the emergency plan and indicating so in writing
  • Providing standing orders for use of the AED
  • Reviewing documentation from any instances when the emergency plan is initiated and the AED is used
• A club's emergency plan and AED plan should be coordinated with the local EMS provider. (Note: Most of the product providers offer this assistance.) Coordinating with the local EMS provider refers to the following:
  • Informing the local EMS provider that the club has an AED or AEDs
  • Informing the local EMS provider of the location of each AED at the facility
  • Working with the local EMS provider to provide ongoing training of the facility's staff in the use of the AED
  • Working with the local EMS provider to provide monitoring and review of AED events
• All incidences involving the administration of an AED must be recorded and then reported to the physician who is providing AED oversight as soon as possible, but no longer than one day. (The Health Information Protection and Portability Act [HIPPA] does not allow medically sensitive information to be released to anyone other than the medical director.)
• Each club should have an AED program coordinator who is responsible for all aspects of the emergency plan and the use of the AED, as outlined in the standards of care detailed in this book.
• All staff likely to be put in a situation where they may have to administer an AED should be appropriately trained and certified in a course that incorporates the administration of the AED from an accredited training organization. Currently, the AHA and the American Red Cross (ARC) provide AED basic life support training and certification that involve a minimum of four hours of direct-contact training. AHA training and certification lasts approximately two years, while the corresponding ARC program lasts for about one year. Records of training and retraining should be maintained in staff personnel records or as part of the documentation of the facility's emergency response system.

An effective and rapid PAD system actually depends on bystanders participating in rapid recognition of potential sudden cardiac arrest and the deployment of an AED for possible use. For this reason, health/fitness facilities are encouraged to work with their medical directors and EMS support systems to carefully define prudent and appropriate ways to include all facility members and users in the emergency response system. This process may include consideration of how members and users might be involved, directly or indirectly, in accessing and deploying an AED and at what point during the emergency protocol that step may be required (e.g., sudden collapse of an individual and no staff member is immediately present). Written instructions might be provided to every member or user concerning the approved PAD program in the facility, what the bystander or user response should be in an emergency, and where the AED is located. Likewise, orientation of new facility members might include a simple printed information card indicating the location of pertinent emergency response postings in the facility; the locations of the emergency telephone and AED; which staff members may need to be employed to handle an emergency; and where their offices are located, should EMS activation be needed.

The orientation for new users could also include visits to locations in the facility to point out areas that are listed on the emergency response information card they have been given. While it is recognized that developing an appropriate way to involve all users in a PAD program will need careful and thoughtful consideration, this process may help to reduce the time between cardiac arrest and defibrillation, when the cause of collapse is ventricular fibrillation, especially in medium to large facilities during those times when member, user, and staff presence is minimal.

The AED should be monitored and maintained according to the manufacturer's specifications on a daily, weekly, and monthly basis, and all information in that regard should be carefully documented and maintained as part of the facility's emergency response system records. AEDs provide this function through an automated process.

At the present time, the use of AEDs in the health and fitness industry has remained somewhat controversial. In 2003, for example, the International Health, Racquet and Sportsclub Association (IHRSA) released a position statement on AEDs that indicated that while the Association thought that health/fitness facilities should consider the installation of an AED, it did not think that AEDs should be mandated for them. The AHA and ACSM released a joint position statement in 2002 that recommended the implementation of AEDs in health/fitness facilities (appendix I). As of December 2010, only 11 states (Arkansas, California, Illinois, Indiana, Louisiana, Massachusetts, Michigan, New Jersey, New York, Oregon, and Rhode Island) have passed legislation that requires health/fitness facilities to have AEDs. Table 3.2 provides a summary of the various states with AED legislation and some of the general aspects of that legislation. It should be noted that in four states, legislation allows unstaffed facilities (e.g., 24-hour key-card access facilities, hotel-based facilities) to use AEDs without having trained employees present. As of December 2010, the state of Wisconsin had legislation pending regarding AEDs in the health/fitness setting, and it should be expected that in the future, additional states will pass legislation requiring health/fitness facilities to provide access to AEDs. In reality, most of the premier health/fitness facility operators in the United States have already made AEDs an integral part of their emergency response systems. It should be noted that AED use in health/fitness facilities is not yet a global issue, as the European Union has yet to establish legislation in this regard.

The American Heart Association, in its Guidelines for Emergency Cardiac Care, indicates that while a facility should be able to get a response time from collapse caused by cardiac arrest to defibrillation of four minutes or less, the best means of achieving this objective is to provide AEDs in locations that staff or the public can reach within a 1.5-minute walk. If an individual were to walk at a rate of 3 mph (4.8 km/h), this effort would involve a distance of slightly over 500 ft (150 m). As a result, a facility operator should consider the time needed to reach various sites within its facilities from various locations and then identify those locations that would allow its staff, members, or the public to access an AED within a 1.5-minute time span. If a facility occupies multiple floors, it might be wise to consider locating an AED on each floor to ensure that the device can be reached within the appropriate time limitation.

A skills review and practice sessions with the AED should be held every six months, as recommended by the AHA's Emergency Cardiac Care Committee and a number of international experts. While some experts recommend practice drills as often as once a quarter, no research exists that would indicate less frequent rehearsal poses any greater risk to the members and users of a health/fitness facility. The key takeaway of this standard for health/fitness facility operators is that conducting a physical rehearsal (e.g., practice drills) at least every six months will help ensure that the staff of the facility are prepared to respond to cardiac events that take place on the premises of the facility.

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