Increasing community public access to defibrillation

Why have cPAD schemes?

In 2009, the UK Resuscitation Council gave clear guidance on where a defibrillator should be positioned. Current international resuscitation guidelines (Rescuscitation Council, 2009) advise that evidence supports the establishment of public access defibrillation programmes when:

In real terms, this means most rural locations in the UK, and some city centre locations, with or without existing community first responder (CFR) cover. Over the past 10 years, many ambulance services in the UK have established CFR schemes, which are now considered essential local services for supporting some types of 999 incidents.

Statistically, based on data from the UK ambulance service, CFR schemes attend around 1 in 10 sudden cardiac arrest (SCA) events, mainly due to there being insufficient CFR volunteers to provide full geographical and full day/night cover.

cPAD are accessible 24 hours, 7 days a week, 365 days a year, and so are generally more readily available and can result in higher survival rates. The survival rate for cPAD schemes, based upon the latest clinical evidence in the UK, is approximately 26% (to leave hospital) compared to locations without the benefit of a cPAD at less than 3% (Colquhoun et al, 2008). Figures from the US, notably Seattle, where bystander CPR schemes are well established, only have a survival rate of 7.6% without defibrillation (Science Daily, 2009).

cPAD schemes are not in any way competitive to community first responder schemes, but are a natural adjunct to them, particularly where the cover by the CFR scheme is patchy and the numbers of calls do not justify the cost of a CFR scheme, or calls are intermittent or more than 5 minutes travel to the patient. Recovery from a sudden cardiac arrest is totally time dependent, the outcome degrading by 14–23% per minute post event (Figure 1) (De Maio VJ et al, 2003). Hence it should not be an either/or, but an integrated approach to better patient outcomes.

cPAD schemes are being installed for local villages by local community first responder groups, or other local village organizations; such as local charities (e.g. Lions, Rotary, Masons) or parish councils. Recently a CFR scheme that was one of the first to be established in the UK about 10 years ago, installed a Community Heartbeat Trust (CHT) cPAD scheme in its home village. ‘We installed the cPAD (at a country pub) as we were a mile away from the core of the village and there is no CFR volunteer nearby’ said Anne Chapman, one of the founders of the Essex based CFR group. ‘We are also intending to install one in the post office and also the other pub in the village.’

This responder scheme has 13 trained and active responders in a 9 square mile area and yet they cannot guarantee a response to all locations in less than 5 minutes. They concluded that a cPAD was a valuable adjunct to providing a local community resource for any possible cardiac arrests.

Yellow boxes

The CHT provides support for local communities to place defibrillators in vandal resistant heated secure boxes, coloured yellow for ease of visibility and rapid recognition. The colour has been chosen after testing with members of the public and in conjunction with the ambulance service (despite claims by other manufacturers there are, as yet, no central or international standards for AED box colour and various colour cabinets exist).

The AED cabinets can be lockable or not, there are good arguments either way, although in rural locations lockable is favoured both by ambulance services and local communities for a variety of reasons.

Ambulance services

All ambulance services across the country support the provision of cPAD schemes. Many have active programmes underway with the CHT. There are already several thousand defibrillators in large shopping centres and high footfall areas such as train stations and sports centres as a result of the national defibrillator campaign which ran several years ago.

Over the past few years, local communities have purchased defibrillators to try to provide their own schemes in village halls and local housing estates. Some of these have saved lives but, in general, have been un-coordinated and may be unknown to the local ambulance service, and in some instances have lacked ongoing equipment support.

‘If we could only get every GP surgery, every dental practice and most retail pharmacies placing defibs outside their premises, this would add an estimated 40 000 defibs into the public access at very little cost,’ says Martin Fagan, secretary of CHT.

With the central co-ordination and direction of such charities as the CHT, standardization of approach; training and equipment support; and increased purchasing power, is available to the benefit of the local community. It also provides a central point of liaison with the ambulance services, PCTs and Department of Health, as well as other charities and organizations involved with health in the community.

Case histories

Do these schemes work? A very telling example is that of the success of a cPAD scheme that occurred in Norfolk late in 2009, a scheme established by Holt responders. This is outlined in Box 1. This is not a unique example. However given the potential for survival, and the need for a fast response, cPAD schemes can and will continue to save lives.Another case history is outlined in Box 2.

Case history one

A regular visitor to Kelling Heath Holiday Park in North Norfolk had reason to be grateful to a local scheme which has placed a defibrillator at the holiday park and trained staff how to use it. The visitor was using a rowing machine in the gym when he experienced chest pain and collapsed. When staff first aiders arrived at his side, two started chest compressions and a third went to fetch the defibrillator which had been installed on site in September 2009. After shocking and further compressions, he began breathing normally. An ambulance arrived on scene shortly afterwards and gave oxygen therapy before transporting the patient to the Norfolk and Norwich University hospital where he made a good recovery. Staff at Kelling Park had been trained to use the defibrillator by the East of England Ambulance Service through the Holt and Communities First Response Defibrillator Project, in association with the Community HeartBeat Trust. The defibrillator had been funded by a donation. Andrew Barlow, responder manager for the ambulance service in Norfolk said: ‘The more of these automatic defibrillators in the community the better as they really can make the difference between somebody surviving a heart attack or not. We will be continuing to provide training and ongoing support to these communities.’

Case history two

The challenge for any local response group is how to be contacted in the least possible time. The solution found in Carlton, Leicestershire, where a community defibrillator has been installed by the Community HeartBeat Trust (CHT), is to use an internet phone working off a broadband modem to enable rapid and easy communication amongst the village responders. Carlton has six volunteers willing to respond in the event of a cardiac arrest in the village. Each volunteer responder has been trained by the local community first responder team in how to recognize a cardiac arrest, and how to undertake CPR and administer the defibrillator. Each volunteer has a standard cordless BT phone attached to an adapter that is plugged into a broadband modem. All of these adapters are programmed to the same telephone number. When there is an emergency in the village, 999 is always called, followed by the village emergency number which rings simultaneously every one of the six phones. The first volunteer to answer takes the call and all other phones stop ringing. The first volunteer will take all the details and rush to the patient and commence CPR. En-route, he will call the village emergency number again and the next volunteer will rush to collect the defibrillator, or to assist as required. The defibrillator is positioned in the local telephone box, central in the village. This saves precious time and there is a second volunteer on hand to assist.The local ambulance service also has the village emergency number and can call for assistance from the local village responders as well. Nigel Axelrad, the Carlton scheme co-ordinator, stated 'We have worked with the CHT and our local CFR group to have a village defibrillator, positioned in the village telephone box. We had a challenge to see how best we could communicate in the fastest possible way amongst the village responders and this method suited our village well. We would recommend this approach to any similar cPAD scheme’.

Professor Douglas Chamberlain has a similar view: ‘Sudden out-of-hospital cardiac arrest cannot be a problem for ambulances if one wants best results.’ Professor Chamberlain has been an advocate for community defibrillation, and in particular members of the public both having access to defibrillators more readily, and also in being trained in good CPR techniques.

Telephone boxes

Defibrillators are also finding a place in telephone boxes. Working with British Telecom and the electricity providers, the CHT has now delivered several locations where redundant village telephone boxes have been used to house defibrillators. ‘The use of these iconic locations is ideal for defibrillators,’ says Mark Johnson, manager, BT Payphones. ‘They represent both an easily recognizable location, a use for a redundant but much loved icon, and also present a microclimate that helps support and protect the defibrillator.’

Another location with a telephone box AED solution is Chedworth in Gloucestershire, a project run with Great Western Ambulance. Commenting from Great Western Ambulance, Kevin Dickens said, ‘Developing this partnership with Community Heartbeat Trust is helping Great Western Ambulance Service extend our vision in creating a cardiac safe environment. This continues to build on our goal to make automated external defibrillators (AED) available to anyone at any time anywhere, achieving this will result in lives being saved.’

Conclusion

The excellent response to the work of CHT in 2010 makes the CHT one of the leading charities in rural community defibrillation, and its success is attributable to the excellent relationships with the ambulance services and local communities alike.

This has led to a reputation for delivery and innovation. CHT is not the only organization working in this area, but CHT serves to support local communities through and in conjunction with their local ambulance service, and in this way are seen as partners to the ambulance service.

Being ‘not for proft’ ensures almost all donations are used solely to fill the objects of the Charity. To date, CHT has projects working with 7 out of the 11 ambulance services in England, Wales Scotland and Northern Ireland.

cPADs should be as common as fire extinguishers and they are almost just as cheap. If a village or village organization is interested in a cPAD scheme, or just wishes to make a charitable donation, please contact the CHT via the website: www.communityheartbeat.org.uk, or e-mail: secretary@commuityheartbeat.org.uk, or via the local ambulance service.