Making a Difference in the Community

The most practical approach to the treatment for out-of-hospital cardiac arrest is to provide rapid emergency medical care for the victims. The American Heart Association Chain of Survival Strategy (early recognition, early EMS notification, early CPR, early defibrillation, and early ACLS support) is designed to optimize a patient’s chance of survival of out-of-hospital cardiac arrest3 (Figure 1). In the few communities that have implemented this system, they are reaping great success. For example, 27% of patients with witnessed out-of-hospital cardiac arrest due to VF in Seattle, Washington, survived to leave the hospital when bystanders performed CPR. Only 13% survived without bystander CPR.5 Similar results have been achieved, noted in a recent publication, in the state of Minnesota. Still, rapid defibrillation, which is the definitive treatment for VF, is not applied with bystander CPR. The Public Access to Defibrillation (PAD) trial investigators reviewed literature on times of defibrillation-equipped ambulances to arrive at a victim. In many cases, the response time is 6-8 minutes. The investigators report that to the best of their knowledge, no city has been able to provide defibrillation for the majority of out-of-hospital cardiac arrest victims within 5 minutes of recognition of an event.6 Automated external defibrillators (AEDs), capable of automatically detecting and treating VF, have made it possible for the public to defibrillate safely. These devices defibrillate the heart with a high degree of sensitivity and specificity. Recent published studies have reported results showing that defibrillation by targeted responders (police officers, fire fighters, airline flight attendants, and security officers) is feasible. These targeted responders were able to defibrillate safely and effectively with a short response in the field, which resulted in an increase in survival by 39-71%.7-9 If survival increased nationwide from 5 to 10% of events, the premature death of approximately 30,000 persons could be prevented in the US annually.10 Alternate methods for providing early defibrillation need to be considered because arrival of a trained person is often delayed. One such alternative is the implementation of a community-based response system of non-medical volunteers. These are volunteers who would not typically respond to a medical emergency and are located in high-population areas. Such a strategy is called Public Access to Defibrillation. With our entire book knowledge on Advanced Cardiac Life Support (ACLS), coupled with the experience any given cath lab nurse or technologist possesses on arrhythmias and in hands-on use of a defibrillator, an excellent opportunity exists to utilize our given work skills to make a difference in our own community. In addition to encouraging public access to defibrillation, many cath lab nurses and technologists have a see one, do one, and teach one mentality. This personality offers a great opportunity to train the lay public. This concept arose out of a casual conversation during a recreation team meeting of 7 members of Cool Spring Baptist Church, met on a December evening. Cool Spring, in Mechanicsville, which is a suburb of Richmond, Virginia, has an average Sunday attendance of 1200 people attending 3 worship services. Within the past 3 years, the church has built a recreation facility which is attached to the main building. This facility has a full-length basketball court, full game room, full weight room, running track, and aerobics room. During the week, an average daily attendance of 300 people pass through the doors for exercise and fellowship. In addition, there are numerous dinner socials, musical programs, group meetings, and community-based programs that bring numerous people through the doors of the church and recreation facility. Cool Spring has obviously blossomed into a high-volume outreach center. During the meeting, in which an EMT and a cath lab professional were both present, it was decided that for a facility this large and with a majority population of 35(+)-year-olds, an AED was a sound and ethically smart idea. In reality, how could trained professionals with the knowledge of how effective an AED is, not champion this effort? After all, it would take only 1 death and then we would surely get an AED. Therefore, why not do our best to prevent the one death that most likely would be a friend? In order to purchase a defibrillator, we were looking at an acquisition cost of about $2000“$2500. Prices will vary, but this is a good benchmark. I have since learned that one of the vendors has made a significant price reduction of about 30%. The decision was made that we would save and make the purchase. As fate would have it, the city of Richmond, working with the local chapter of the American Heart Association (AHA), initiated a grant program that is entitled Heart Save Richmond. As a part of this program, the city of Richmond was going to purchase an AED for qualified centers. We immediately notified the local AHA and had LaDonna Austin, Project Coordinator of Heart Healthy-Stroke Safe Richmond, visit our facility. During this visit, we gave a tour and provided LaDonna with the type of programs and the volumes of people that are in this facility on a daily basis. Within less than two weeks, we were approved and had the AED mounted on the wall (Figure 2). Truly an amazingly fast process! Now we have this AED on the wall, but what next? We are setting out to train all of the church staff and volunteer workers first. This number is estimated at 100. We chose this group first due to the fact that they are the most common group present in the facility on a daily basis. Our facility already has a certified Heartsaver AED Instructor, Joyce Hawkins, RT (Figure 3). In order to be a Heartsaver AED instructor, you need to have your BLS certificate updated within 6 months and then take a two-day course. The BLS re-certification and the Heartsaver Instructor course are graciously paid for by our institution. After passing your instructor exam and being mentored for one class, you have become a Heartsaver instructor. Currently, we have scheduled 2 classes a month. We schedule one class during the weekday and one class during the weekend. Our hope is to have a time slot for everyone interested. We have offered a introduction course that takes two hours for people just wanting the basics with no test and no certification card, and a four-hour class, where attendees take a test and receive a certification card. The church has purchased 2 sets of mannequins and two AED trainers. We plan on having classes given to no greater than 6 people at one time. After this group is trained, we will broaden the program, possibly to the community. Our vision is that everyone who has a volunteer or staff position within the facility be capable of performing CPR and be able to open up the AED and follow the instructions given by the machine prior to EMS arriving. We feel that with just this basic and rather minimal knowledge, we will be able to significantly increase of chance of survival for a person experiencing cardiac arrest within our facility. The data are quite clear. In order to increase survival from sudden cardiac arrest, the AHA chain of survival needs to be implemented rapidly. There is no quicker way to provide defibrillation than to have an AED on site. Since the AEDs manufactured today are extremely user-friendly, the benefits of having an AED on site are obvious. The yearly maintenance on this program is minimal. The AED needs to be checked regularly for battery life, which apparently needs replacement every 5 years, and then people need to be re-trained on a semi-annual basis. We feel that the addition of the AED in Cool Spring Baptist Church has been welcomed. We are extremely grateful to the efforts of the American Heart Association, and the Heart Save Richmond program. It is felt that training people in our church will not only help us, but since AEDs are becoming a more prominent fixture in the community, the additional trained personnel could benefit a victim of sudden cardiac arrest outside our walls. This truly represents an opportunity where cath lab personnel can make a difference in their community by using a skill that is so common that it is probably taken for granted. So the next time you are in your church, gym, or local club, look around the room and know that the person you see next to you could possibly be the life saved if you take that the first step to initiate an AED program. Thomas Maloney can be contacted at Thomas_Maloney@merck.com. CLD

References1. Centers for Disease Control. State Specific Mortality from Sudden Cardiac Death — United States, 1999. MMWR 2002;51:123–126.2. Gillum RF. Trends in Acute Myocardial Infarction and Coronary Heart Disease Death in the United States. JACC 1994;23:1273–1277.3. Cummins RO, Ornato JP. Improving Survival from Sudden Cardiac Arrest: the “the Chain of Survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83: 1832–1847. 4. Nichol G. Effectiveness of Emergency Medical Services for Victims of out of hospital cardiac arrest: A meta analysis. Ann Emerg Med 1996;27:700–710. 5. Cummins RO. Survival of out of hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med 1985; 3(2):114–119. 6. The PAD Trial Investigators. Resuscitation 2003;56:135–147.7. White RD. High Discharge survival rate after out of hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med 1996;28:480–485.8. Valenzuela TD. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. NEJM 200;343:1206–1209.9. Page RL. Use of automated external defibrillators by a US airline. NEJM 2000;343:1210–1216.10. Nichol G. Potential cost-effectiveness of public access defibrillation in the United States. Circulation 1998;97: 1315–1320.