An estimated 60,000 out-of-hospital cardiac arrests occur each year in the UK and, as such, organisations are encouraged to consider having automated external defibrillators (AEDs) in the workplace. The decision to install an AED should, says Mike Sopp, be based on a needs assessment.
Sudden cardiac arrest (SCA) is a leading cause of premature death in this country. Survival rates from such arrests range between 2% and 12%, but with immediate treatment many lives can be saved. Survival rates as high as 75% have been reported where cardiopulmonary resuscitation (CPR) and defibrillation are delivered promptly.
Many organisations are now considering the introduction of AEDs in the workplace, particularly where members of the public may be present. When doing so, the decision to install and utilise an AED should be based upon a suitable and sufficient needs assessment.
Purpose of defibrillators
A cardiac arrest is the complete loss of the mechanical function of the heart. The most common cause of SCA is ventricular fibrillation (VF). In this condition, the heart is unable to pump oxygen to the brain and other vital organs. Death occurs within minutes unless the normal rhythm is restored by defibrillation.
Defibrillation is the only treatment that can restart the heart and restore a normal heart rhythm. Many victims of SCA can survive if immediate action is taken while VF is still present. Research shows that applying a controlled shock within five minutes of collapse provides the best possible outcome. For every minute that passes chances of survival decrease by 14%. Successful resuscitation is unlikely once the heart has ceased to beat.
The British Heart Foundation (BHF) states that “this indicates the need for defibrillators to be deployed strategically in areas of greatest need, areas where there is a high incidence of cardiac arrest and in areas where it is difficult for an ambulance to get there quickly or where large crowds gather”.
Indeed, the Resuscitation Council (UK) (RC(UK)) and BHF state that the introduction of AEDs has been described as “the single most important development in the treatment of SCA”.
An AED is a sophisticated computerised device that analyses the victim’s heart rhythm, determines the need for a shock and applies a shock in an attempt to restart the heart, or advises that CPR should be continued.
The needs assessment
The Health and Safety Executive (HSE) states that “there is no legal bar to employers making a defibrillator available in the workplace if the assessment of first aid needs indicates such equipment is required”.
In terms of AEDs, the RC(UK) states that “completing a first aid needs assessment entails making an estimate of the risk of a cardiac arrest occurring at a location and considering the potential consequences if it were to occur”.
In doing so, the RC(UK) suggests that the likelihood of an SCA occurring will be influenced by the:
number of people using a facility (including the public if first-aid treatment is offered to them)
risk of cardiac arrest occurring at the site due to the profile of users (eg predominantly middle-aged males or older persons)
type of work activities or premises (eg physical exertion or stressful environments).
Generally, cardiac arrest is more common with increasing age and, clearly, the more persons present the more the likelihood of an arrest occurs. Therefore, the person completing the assessment will need to determine the number of persons for whom first aid will be provided (including the public, visitors, contractors, etc).
The RC(UK) then suggests applying a 1–5 scale with 1 being a rare occurrence of SCA and 5 being almost certain of occurring. Of note, the guidance to this states that “at present there is insufficient published evidence to give precise or dogmatic advice for an individual location and the rating score applied has to be a ‘best-guess’ or estimate”.
The 1–5 scale is also applied to consequence but RC(UK) highlights that “cardiac arrest is uniformly fatal (unless treated), so the score will always be 5” and that “even if resuscitation is successful, the impact on the individual will be significant, so the score will remain the same at 5”.
The scores are then combined in a 5x5 matrix to give a determination of need, details of which can be found on the RC(UK) website.
Of interest, international resuscitation guidelines advise that evidence supports the establishment of public access defibrillation programmes when the:
frequency of cardiac arrest is such that there is a reasonable probability of the use of an AED at least once in two years
time from call out of the conventional ambulance service to delivery of a shock cannot reliably be achieved within five minutes
time from collapse of a victim until the on-site AED can be brought into use is less than five minutes.
This last factor, in particular, suggests that the needs assessment should be taking into consideration of the location and use of an AED.
Location and use
RC(UK) notes that the best chance of successful resuscitation will be when defibrillation and other first-aid procedures are ideally carried out within in the first three minutes.
As such, RC(UK) states that “the only practicable action possible is to ensure that in an emergency the location and accessibility of the AED is easy and well known to all staff”. Therefore, factors to consider in the assessment will include:
availability for timely deployment
safety risks such as cold weather locations
security of the AED from tampering, theft or vandalism.
AEDs should not be stored in locked cabinets as this can delay deployment. However, this may have to be tempered with the risk of tampering or vandalism. Thought may have to be given to whether or not heated cabinets are required if the device is to be stored in an area susceptible to cold weather as the electrode pads may not function correctly if cold.
Thought will also have to be given to the use of an AED. Both RC(UK) and HSE guidance recommend that “it is essential to have people on site who are willing to be trained to use the AED” but that “it is the view of the Resuscitation Council (UK) that the use of AEDs should not be restricted to trained personnel”.
The whole principle of an AED is that it can be used by those who have no specific training. However, it should be recognised that there may be reluctance by those nearby to use the equipment without training or even to be trained in the use of an AED. These factors will need to be considered in the assessment.
Decisions on location and training will have cost implications including initial purchase of AED (or rental), ancillary equipment and replacement consumables, initial and ongoing training, regular maintenance and checks (either in-house or remotely). These factors will also need to be considered as an overall cost/benefit analysis.
Corporate and individual liability
Liability of both individuals and corporation along with reputational risk may influence the installation of AEDs.
The use of AEDs by individuals, whether they are trained or untrained, can be a cause for concern as they may feel at risk of having a claim brought against them if that casualty suffers harm as a result of their intervention.
Potential liability can arise at common law although there have been no reported cases at all where a casualty has successfully sued someone who came to their aid in an emergency. In theory, a claim might be brought against an individual in either:
the law trespass, on the grounds that an intervention constituted an assault on the casualty
the law of negligence for a breach of duty of care towards the casualty.
Employees should be reassured that they will not be subject to any criticism or blame, and will be shielded by the employer’s liability insurance against any litigation if the person dies.
In respect of an employer’s duty of care where employees use an AED, to be held liable it would have to be shown that the intervention had left the victim in a worse situation than if there had been no intervention.
Using an AED cannot make a victim’s condition worse since the device will only discharge its shock if the victim has a heart rhythm that will lead to death if they do not receive a shock.
As such, the RC(UK) states, “it is difficult, in the circumstances under consideration, to see how a rescuer’s intervention could leave someone worse off since, in the case of cardiopulmonary arrest, a victim would, without immediate resuscitation, certainly die”.
The guidance also makes reference to potential liability if the organisation had not provided an AED and an individual suffers a cardiac arrest. It states that for a claim to be successful it must be shown, at the least:
that the people who generally used the organisation’s premises were at a particular risk of cardiac arrest (ie that there was a fairly high risk of potential harm)
that it was common practice among such organisations to have an AED available.
However, where an AED is provided, it could be seen that the organisation has a duty to ensure the AED is available for use and is well-maintained.
Last reviewed 8 June 2017