Strategies for community defibrillation with automated external defibrillators (AEDs)
AED programmes within the emergency medical system (EMS)
Recommendation 1
The goal of achieving an effective AED programme within the EMS should become a fundamental objective in every European country. Accordingly, it is recommended that an AED and properly trained personnel should be placed in every vehicle that may transport patients at risk of cardiac arrest. This should be the first priority for an early access defibrillation programme.
AED programmes outside the EMS
Analysis of the literature shows that there are three main strategies for the implementation of defibrillation programmes outside the EMS: community programmes, on-site programmes, and home programmes
Recommendation 2
Several models for the implementation of AED programmes outside the EMS have been described: we have identified three main strategies that have different and to some extent opposite characteristics (See below and refer to Table 1 of the original guideline document). It is recommended that once the priorities of implementation of an AED programme within the EMS have been achieved, a careful analysis is conducted in order to identify the community model that is most suitable for the specific environment. A cost-effectiveness analysis is an essential part of the implementation strategy. Every hospital should analyse whether the goal of early defibrillation is achieved and AED implementation can be an important element in improving the in-hospital chain of survival. Home programmes are still in a preliminary phase of implementation: families with a genetic predisposition to sudden cardiac death and families with high risk individual(s) who are not scheduled for, or cannot receive, an implantable cardioverter defibrillator (ICD) represent the primary target for pilot projects on home defibrillation.
Table 1: Strategies for early defibrillation outside the emergency medical system
| |
Community Responder |
On site responder (including bystander defibrillation) |
Home responder |
| Location of victim |
All areas, including home |
Public or private areas, excluding home |
Home |
| Training level |
High |
Moderate to untrained (for bystander defibrillation) |
Moderate |
| Number of reachable victims |
High |
Limited |
Low (relatives only) |
| Number of AEDs needed |
Moderate |
High |
One per home |
| Time interval collapse–defibrillation |
Reduction is limited |
Potentially very short |
Very short |
AED: legislation and organisation in Europe
Recommendation 3
Legislation in Europe is heterogeneous, but where it has relevance to AEDs it either has permitted or is likely to permit their use by nonmedically qualified first responders. Automated external defibrillation does not require establishing a clinical diagnosis and therefore it should be lifted from the list of actions "reserved to doctors." Slow implementation is mainly the result of limited perception of the importance of early defibrillation programmes and by traditions and reluctance to "de-medicalise" the act of defibrillation. The lack of data on cost-effectiveness may discourage the support of governments for AED programmes. Therefore, this type of economical evaluation should be part of any planned developments. European legislation or recommendation issued by European policy makers and supported by all relevant major health care and scientific societies could promote implementation of this life saving strategy that is strongly supported by scientific evidence.
How should AED programmes be organised in Europe?
Recommendation 4
The Panel has reached a Consensus that an effective early defibrillation programme requires the setting of priorities and the integration of at least five different areas of activity:
- Analysis of local conditions and identification of priorities
- Identification of intervention protocols
- Identification and training of responders
- Efficient data – reporting and quality control systems
- Constant maintenance
All such activities are tightly linked: if one fails, the entire programme will probably be threatened. Accordingly, planning a defibrillation programme should include strategies and resources for all the components that will be discussed below. Furthermore, in order to establish an out-of-hospital early defibrillation programme with the endpoint of providing effective care for the largest possible section of the community in any given area, organisers should try to follow logical steps of development.
Analysis of local conditions and identification of priorities
Recommendation 5
In order to establish an effective programme, every attempt should be made to acquire exhaustive data on the prevalence and epidemiology of sudden death in the area. This allows the requirements for the success of the programme to be set and quantification of the resources (manpower and devices) that will be required. Although it is appreciated that detailed baseline epidemiological data may be lacking in some areas, it is important to consider that the data collected during the planning phase can have an impact on the cost-effectiveness and the overall success of the programme.
Identification of intervention protocols
Recommendation 6
The dispatching system and the clinical intervention protocol need to be standardised. A centralised dispatching system that can activate all responders is considered the best model. The intervention protocol should standardise all clinical actions following arrival on scene and include collection of all relevant data for systems monitoring.
Identification and training of first responders
Identification of responders
Recommendation 7
The identification of potential responders should be based on an analysis of local conditions. Where the EMS can provide adequate coverage, reinforcing the existing system may be an effective strategy. Deployment of AEDs at fixed locations in the community represents an alternative strategy that should now be considered feasible, safe, and effective even if it requires training of a large proportion of the community in the use of AEDs and in alerting the EMS system.
Training of responders
Recommendation 8
Training of responders should include basic life support (BLS) and AED skills, the duration depending on a number of factors including previous knowledge and skills of the target group. The need for teaching BLS to nonmedical personnel is currently a matter of debate, as some successful experiences have been conducted based on training of defibrillation only. For the time being it seems reasonable to support the view that combined BLS and AED training should be recommended even if in some circumstances it may be appropriate that AED training precedes BLS training.
Data reporting and quality control system
Recommendation 9
It is important that in every early defibrillation programme data collection and assessment of the results are carefully designed. International standards for uniform data collection are being developed. This is essential for monitoring and benchmarking of the programme. Continuation of a project is likely to require evidence of its efficacy and its quality that will have to be demonstrated through a data collection protocol that is methodologically sound.
Programme maintenance
Recommendation 10
It is important that, when budgeting the cost of an early defibrillation programme, the annual costs should include an allowance for maintenance including equipment, personnel, training, and monitoring costs.
