Rice University's Public Access Defib Proposal

Strengthening the Chain of Survival at Rice University: A Proposal for Public Access Defibrillation

Prepared by Noah Reiter EMS Director Rice University

Sudden Cardiac Arrest: Sudden cardiac arrest (SCA) is a medical condition that kills approximately 250,000 Americans annually, according to the American Heart Association (AHA). SCA refers to any number of conditions that cause an electrical disturbance in a person’s heart and, without warning, causes it to stop beating. In such a scenario, if a certain sequence of interventions (collectively known as the “Chain of Survival”) is not initiated and carried through promptly, then the victim’s chance of survival decreases dramatically with each passing minute. In the past four and a half years, there have been 7 cases of SCA on the Rice University campus. Three of these people, two employees and one visitor, ultimately died. Recent technological improvements, in addition to the signing of important legislation in the State of Texas offer enormous hope to increase survival rates for victims of SCA.

The Chain of Survival: The AHA has defined the Chain of Survival as a sequence of interventions that, when performed rapidly after a person’s heart stops beating, will give a victim of SCA the best chance for survival. The links in the Chain are early access, early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced care. Just as in any other chain, the Chain of Survival is only as strong as its weakest link. The links are depicted in the following diagram:

Early access, the Chain’s first link, refers to the public’s ability to rapidly recognize an emergency and summon emergency services through easy-to-remember telephone numbers, such as campus extension 6000 or 911 (for off-campus emergencies). Education of the public, as well as Good Samaritan Laws, enable bystanders to initiate early CPR, the second link of the Chain, to victims of SCA prior to the arrival of trained rescuers. These first two links have been in the public’s hands for many years now. Once trained medical professionals arrive on the scene, the last two links of the Chain are initiated and carried through. Recent studies that have indicated poor outcomes and low “save” rates of SCA victims prompted recommendations on how to further strengthen the Chain of Survival. It has been found in documented studies that CPR is both infrequently performed and infrequently performed well prior to the arrival of emergency medical services (EMS). Furthermore, it is now clear that CPR generally does little more than to “bridge the gap”

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or buy the patient some time until trained medical professionals can arrive and take over life saving procedures. The true, definitive treatment for SCA is defibrillation – the delivery of electricity to a pulseless person’s heart. The victim’s chance for survival decreases by 10% for each minute that defibrillation is delayed (see attached graph). The chances for a complete neurological recovery for victims of SCA are greatly increased by early defibrillation. Until recently, defibrillation could only be provided by physicians or paramedics through the use of fairly complex devices known as manual defibrillators. The arrival of a device known as the automated external defibrillator is quickly placing this life-saving technology into the hands of lay rescuers.

Automated External Defibrillation: The strong recommendations of groups such as the American Heart Association have helped to foster incredible advancements in defibrillation technology. The development of the automated external defibrillator (AED) has revolutionized the public’s role in the resuscitation of victims of sudden cardiac arrest. The AHA supports the public’s use of AEDs in the following position statement: Early bystander cardiopulmonary resuscitation (CPR) and rapid defibrillation are the two major contributors to the survival of adult victims of sudden cardiac arrest. Automatic external defibrillation is one of the most promising methods for achieving rapid defibrillation…The AHA believes that this [public access defibrillation] is the next step in strengthening the chain of survival. 4 The ability to use a traditional manual defibrillator requires extensive training in cardiac electrical rhythm interpretation, as well as treatment modalities. Such education is currently only put into practice by physicians and paramedics. An AED is a scaled-down, highly portable, and “smart” version of a manual defibrillator. A typical AED weighs only four to seven pounds and has only two buttons – one to turn the unit on and one to deliver an electrical shock to the patient. Through the use of clear audio and visual instructions, the AED walks the rescuer through the entire process of defibrillation, from connecting the device to the patient to delivering an electrical shock. Essentially, the AED analyzes the victim’s heart rhythm and determines the presence of a “shockable” rhythm. The two lethal dysrhythmias that it can deliver an electric shock to are known as ventricular fibrillation (VF) and ventricular tachycardia (VT). If one of these two dysrhythmias is identified, then the AED charges to a predetermined energy level, advises the rescuers to stand clear of the patient, and instructs the operator to push the “shock” button. If the patient remains pulseless, then the process repeats itself two more times. If the patient’s heart is not initially in VF or VT or after the AED has delivered a total of three shocks, it will instruct rescuers to check the patient for a pulse, and if no pulse is present, to initiate CPR. The simplicity involved in operating an AED is remarkable. A 1999 study demonstrated that a group of sixth grade children learned to

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successfully and safely deliver an electrical shock in an average of 90 seconds (only 23 seconds longer than a group of trained medical professionals) to a pulseless patient after only one minute of orientation to an AED.2

AED Safety: Due to their remarkable design, automated external defibrillators are extraordinarily safe. There have been no documented cases of an AED delivering an inappropriate electrical shock. In a study of the implementation of public access defibrillation at American Airlines, researchers found that an AED had been applied to 101 patients that neither lost consciousness nor a pulse. The AED appropriately did not advise a shock in any of these patients. Conversely, the same study showed that the airline’s AEDs accurately identified a lethal dysrhythmia and advised a shock in all 14 patients that presented with ventricular fibrillation. Six (40%) of these fourteen individuals enjoyed complete neurological recoveries and survived to hospital discharge.1 The ability of the AED to rapidly and accurately analyze (usually within 6-10 seconds) a person’s heart rhythm is truly amazing. While there is a small risk that a rescuer may receive an electrical shock if he or she comes in contact with the patient while defibrillation is taking place, the voice prompts and diagrams of the AED clearly alert the rescuer to this hazard. There have been no reported cases of a lay rescuer having received a shock while utilizing an AED. In the study of sixth graders performing defibrillation after a minimal amount of training, researchers reported that all of the children remained “clear” of the patient during shock delivery.2 Proper maintenance of the AED itself ensures the safety of the device. Every day, the AED performs an internal diagnostic self-test. If anything is in need of repair, the AED sounds an audible alarm and displays a message that service is required. The life of the disposable lithium ion battery is four to five years, at which time the AED will sound an alarm and display a message indicating that the battery needs replacement.

Liability: Fortunately, the Texas Legislature enacted House Bill Number 580 (HB 580) in May of 1999. This bill provides legal protection to individuals who attempt to resuscitate a person in cardiac arrest through the use of an AED. SECTION 2, 74.001(a) of HB 580 reads as follows: A person who in good faith administers emergency care, including using an automated external defibrillator, at the scene of an emergency but not in a hospital or other health care facility or means of medical transport is not liable in civil damages for an act performed during the emergency unless the act is willfully or wantonly negligent.5 The liability protection is further extended to the institution that owns and maintains the AED in SECTION 3, “This Act takes effect September 1, 1999, and applies to a person or entity that possesses an automated external defibrillator…”5

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In fact, there are several known successful lawsuits against organizations that failed to have AEDs readily available to their patrons. Two such cases involved Busch Gardens and Lufthansa Airlines. Each corporation was held liable in a customer’s death due to the fact that neither had an AED on site. Since the victim of SCA is “clinically dead,” even if the AED were to malfunction, no harm would have been done. It certainly seems to be more risky to not have an AED should an emergency arise than to actually have AEDs readily available. While Rice University’s offices of Risk Management and General Counsel must still review this proposal and its implications more thoroughly, liability to the University and to individual rescuers should be negligible.

Medical Direction: In order for the University and individuals to be protected from liability associated with the placement and use of AEDs by lay rescuers, medical direction through physician oversight is required. Dr. Carolyn Galloway, REMS’ medical director, will provide medical direction for and oversee the Rice University Public Access Defibrillation program.

Public Access Defibrillation: Public access defibrillation (PAD) is a concept that involves decreasing the time from collapse to defibrillation for a SCA victim, thereby greatly increasing that person’s chance for survival. This time interval is the most vital determinant in the patient’s eventual outcome. While ventricular fibrillation (one of the two shockable heart rhythms) is the most common initial heart rhythm for a SCA victim to be in, the patient’s heart will not sustain this electrical rhythm for very long. Once the rhythm converts to one that cannot be defibrillated, the patient’s window of survival has almost completely closed. The goal of defibrillating a SCA victim while their heart is still in a viable electrical rhythm, usually within two to three minutes after collapse, is exactly why AEDs are being placed in public locations. There are several variations of PAD that are currently recognized and being implemented across the nation (see attachment for a list of just some of the places that have implemented PAD). These are emergency medical responders, traditional public safety first responders, non-traditional on-site first responders, and citizen responders. Currently the Rice University community has access to defibrillation at the emergency medical responder (REMS) and the traditional public safety levels. The on-duty REMS Supervisor carries a defibrillator in the departmental vehicle. In addition, all of the Rice University Police Department (RUPD) officers are trained to use an AED that is carried by one officer on each shift. This redundancy helps to ensure relatively rapid defibrillation on campus. Comprehensive PAD programs are being implemented all over the United States, as well as in other countries. Some of the more common public access defibrillation sites are

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airports, casinos, airplanes, municipal buildings ? , malls, and large businesses. Most commonly, a PAD program will place an AED in a cabinet that hangs on a wall in a strategic location. The AED is accessible by any citizen that happens to be walking by or in the area. In addition to having the AED available to the public, certain employees that work in the area of the AED are trained in its use. These individuals are considered the non-traditional on-site first responders. The two levels of PAD that this proposal addresses are the non-traditional on-site first responders and citizen responders. There are many locations and facilities on the Rice University campus that have been identified as having a need for and have expressed an interest in a PAD site installation. The following factors led to the identification of these locations at Rice University: • • • • •

High probability for an individual having a SCA due to a large number of people frequenting the site. Demographics of the population frequenting the site (i.e. age and preexisting medical conditions). Activities conducted at the facility that tend to initiate / provoke SCA (i.e. physical activity or contact sports). Potential delay in EMS access to the patient. Facility or department manager’s desire to participate in the PAD program.

Identified PAD Sites: The following locations have been identified to have a potential need for a PAD installation. The facility and / or department manager of each location has expressed an interest in participating in this program. The rationale behind the selection of these sites is explained, as is a proposed location for the AED installation. Please also refer to the attached letters of support from the managers of each of the facilities listed below. Football Stadium – With the number of large events that are hosted at the Football Stadium, PAD installations are necessary. Access to patients during an event at this location takes considerably longer than in other areas of campus, due to the layout of the venue, as well as the large gathering of spectators. Additionally, studies have shown that blunt trauma to the chest has produced many instances of SCA in young, healthy athletes during sporting events such as football and baseball. 3 REMS would train on-site first responders, such as ushers, in adult CPR and AED operation. REMS recommends 3 PAD installations in the Football Stadium – one on the east concourse, one on the west concourse, and one near the R Room on the south end of the stadium. Reckling Park – Rationale for installation of a PAD site at Reckling Park is very similar to that for the Football Stadium. As with the Football Stadium, REMS will train ushers in adult CPR and AED operation. REMS recommends 1 PAD installation at Reckling, near the center of the facility. ?

The City of Houston approved an initiative last year that requires all municipal buildings to be equipped with AEDs. Houston was the first U.S. city to implement such a program.

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Gymnasium and Autry Court – Autry Court should have a PAD installation due to both the large crowds that varsity athletics competitions draw and the physical activity that patrons take part in – be it weight lifting, swimming, or playing sports. REMS would train the equipment room employees in adult CPR and AED operation, and install an AED centrally in the facility, near the equipment room. The AED that the Aquatics Department will purchase with fiscal year 2002 funds will be converted into a PAD site along the south hallway of the Gymnasium. This will further strengthen the Chain of Survival at this facility. Shepherd School of Music – A PAD installation at the Shepherd School is highly recommended due to the large number of attendees, as well as their relative age. REMS would train student employees and ushers in adult CPR and AED operation. An ideal PAD location would be in the main foyer outside of Stude Hall. RMC / Ley Student Center – The RMC / Ley Student Center is a high traffic location as well as the site for many large events and functions, such as the President’s Lecture Series, with large numbers of attendees of all ages. REMS would train RMC staff and student information desk and Coffee House employees in adult CPR and AED operation. The best location for an AED in the RMC would be on the wall facing the Coffee House. Cohen House – Due to the use of the Cohen House for special gatherings that draw large numbers of people, it is also a prime location for a PAD installation. REMS would train student and staff employees of the Cohen House in adult CPR and AED operation. Fondren Library – The Library operates 24 hours a day during the academic year and large numbers of people visit the facility each day. The design of the Library has delayed EMS’ arrival at a patient’s side. Fondren employees, such as the circulation desk staff, would be trained by REMS. A good location for this AED would be on the wall facing the circulation desk. Baker Hall – The Baker Institute for Public Policy regularly hosts large events in its facility. Additionally, the attendees of such functions are typically older adults, who are at a higher risk for sudden cardiac arrest. Ideally, an AED would be located near the main commons of the building, and individuals will be identified to receive CPR and AED training shortly. Jones Business School – With the expansion of the Business School, as well as the older age of its student body, the new Jones Business School could certainly benefit from a PAD installation. Identification of a site and the employees that would receive training is currently being explored in conjunction with the Business School. South & North College Serveries – An AED in each one of these facilities would provide coverage for the students, staff, and visitors to five of the nine residential colleges. Training would be provided to food service employees, college masters, resident associates, and coordinators.

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Graduate Apartments – Due to the Graduate Apartments’ location being removed from the main campus of the University, it may be beneficial for this site to also receive an AED. EMS response times to the Graduate Apartments are slightly longer than to locations on the main campus. Facilities & Engineering – The work performed by F&E personnel is both physically strenuous and involves certain health hazards, such as electricity. This group of employees is at risk for SCA, and would benefit greatly from the installation of a PAD site.

Operation of the Public Access Defibrillation Program at Rice University: The Process of Implementing PAD: • Identification of sites (contained within this proposal). • Acquisition of automated external defibrillators and cabinets. • Placement and wiring of cabinets at targeted facilities. • Training of identified non-traditional on-site first responders by REMS. • Placement of AEDs in cabinets. • Public promotion / unveiling of PAD program. The likely sequence of events when someone collapses in SCA after Rice University has implemented PAD is as follows: • Member(s) of public recognize the emergency. • Someone remembers that there is an AED in the facility and goes to retrieve it from the cabinet while others initiate CPR. • Once the cabinet door is opened, Rice University EMS is automatically notified of the incident and location, if no one has already called RUPD Dispatch. • Citizen rescuers apply the AED, the device identifies a lethal cardiac dysrhythmia, advises rescuers to deliver an electrical shock, and the rescuers do so. • The patient regains a pulse just prior to the arrival of REMS, who takes over patient care. • The patient is transported to the hospital by the Houston Fire Department EMS, discharged, and enjoys a complete neurological recovery. This scenario is precisely what has occurred time and again at sites that have already implemented public access defibrillation programs.

Maintenance and Security of PAD Installations: All AEDs and cabinets in the Rice University PAD program will be maintained by REMS. As previously mentioned, the AED performs daily self-diagnostic tests on its hardware, software, and battery support system. If the device detects any malfunctions, an audible and visual alert is displayed. REMS will be contacted in such an instance, and will remedy the maintenance needs of the device.

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Since the cabinets are wired to automatically notify RUPD dispatch and sound an on-site audible alarm each time the door is opened, security concerns should be negligible. In the several years that Chicago’s O’Hare and Midway Airports have had a comprehensive PAD program, none of their devices have been tampered with or stolen. Cost of Implementing PAD at Rice University: The cost involved in implementing PAD at Rice University is inexpensive relative to the associated enhancement of the University facilities and the benefit to both our community and visitors. The breakdown of cost is as follows: LIFEPAK® 500 AED Cabinet for AED Miscellaneous Supplies (CPR barrier device, shears, gloves) Installation of Cabinet Wiring for AED cabinet for notification of EMS / Police CPR and AED training

$2,750 per unit $217.80 per unit $20 per site $500 per site $1,000 per site $30 per person

The projected cost for each PAD installation (with 30 individuals receiving training) is $5387.80. The total cost for the 15 proposed PAD installations is $80,817. While we fully understand that the next budget cycle begins July 1, 2001, we feel sincere about this proposal’s receiving careful consideration for funding prior to fiscal year 2003, due to the significance of establishing such a program at Rice University. If the public access defibrillation program cannot be funded until fiscal year 2003, it is likely that many of the target facilities will be interested in purchasing PAD installations individually during fiscal year 2002. The benefit of this program to the students, staff, faculty, and visitors of Rice University cannot be overstated.

Long-Range PAD Development: With the current and future facility enhancement at Rice University, it is also crucial to develop a long-range plan for extending the proposed public access defibrillation program. This planning and future site identification should be performed in cooperation with REMS. The University is strongly encouraged to consider the need for PAD installations in each new facility, as they are being planned. The design of these new facilities should incorporate PAD sites, as deemed necessary. Logical future installations include the new library and the convocation center. Additionally, if currently existing facilities that were not identified in this proposal have an interest in obtaining an automated external defibrillator, REMS will support and facilitate the equipment acquisition, maintenance, and training.

Conclusion: Rice University is an institutional leader in both Texas and the greater United States. Rice is widely recognized for its diverse offerings such as its outstanding academics and faculty, the innovative research that is conducted here, the Baker Institute

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for Public Policy, and athletics, just to name a few. Rice University’s daytime population is roughly 6,000, not including contractors and visitors. The reputation that Rice enjoys and the many events hosted on campus contributes to the large number of visitors on campus every day. The University took an essential step towards providing for the health and safety of its community members and visitors when it established the Rice University Emergency Medical Services. One of the most important and proactive steps that Rice can take now towards the further provision for the health and safety to the community is the implementation of public access defibrillation. Just having automated external defibrillators displayed prominently throughout the campus will clearly demonstrate Rice University’s commitment to the welfare of its community, as well as Rice’s desire to be a leader among academic institutions. It is difficult to put an actual price on a human life, but if just one person is saved through this initiative, then the public access defibrillation program will have more than paid for itself and Rice University will be commended both for its foresight and its commitment to public health.

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Photographs of Medtronic Physio Control products to be acquired:

LIFEPAK® 500 AED

Wall cabinet for LIFEPAK® 500

Wall placard to be prominently displayed at each PAD site.

Heartstream® PAD installation in Phoenix, AZ Airport. 10

Sampling of Sites with PAD Programs and / or AEDs: Universities: Cleveland State University, OH Ohio State University, OH University of Texas at Austin, TX Tufts University, MA Rutgers University, NJ University of Georgia, GA Sports and Recreational Facilities: Meadowlands Sports Complex, NJ Jack Kent Cooke Stadium, Washington, D.C. MCI Center, Washington, D.C. Rockrimmon Golf Course, CT Residential, Resort, and Hospitality: Polo Club, FL Stardust Resort and Casino, NV Westin Alyeska Prince Hotel & Resort, Alaska Corporate, Industrial, and Retail: U.S. Steel Time, Inc. headquarters Bellevue Square Shopping Mall, WA Hawaiian Electric Company Aviation Industry: Continental Airlines American Airlines British Airways Virgin Atlantic Airways U.S. Airways Northwest Airlines Chicago’s O’Hare and Midway Airports JFK and La Guardia Airports (New York) The Port Authority of NY and NJ Police Departments: Rice University, TX Suffolk County, NY Rye, NY Rochester, MN London, England

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Works Cited 1. Barbera SJ, Hamdan MH, Joglar JA, Kowal RC, McKenas DK, Nelson LL, Page RL, Ramaswamy K, and Zagrodzky JD. Use of Automated External Defibrillators by a U.S. Airline. The New England Journal of Medicine. 2000; 343: 1210-1216. 2. Bardy G H., Comess KA, DeRook FA, Gundry JW, and Jorgenson D (1999). Comparison of Naive Sixth-Grade Children With Trained Professionals in the Use of an Automated External Defibrillator. Circulation. 1999;100: 1703-1707. 3. Kaplan JA, Maron BJ, Mueller FO, and Poliac LC. Blunt Impact to the Chest Leading to Sudden Death from Cardiac Arrest during Sports Activities. The New England Journal of Medicine. 1995; 333: 337-342. 4. Kerber RE, McGoldrick RP, Moss AJ, Nichol G, Ornato JP, Palmer DG, Riegel B, Smith SC, and Weisfeldt ML. Public Access Defibrillation: A Statement for Healthcare Professionals from the American Heart Association Task Force on Automatic External Defibrillation. AHA Scientific Statements. 1995. 5. The Legislature of the State of Texas. House Bill 580. Health and Safety Code. Amended 1999; Subtitle B, Title 9, Chapter 779.

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