Creating an Updated PAD Program in 2009: EP Lab Digest Speaks with Jim Sideras, RN, MSN, MIFireE, CFO, CMO

In this interview, we speak with Jim Sideras, RN, MSN, MIFireE, CFO, CMO. As the division chief for the Sioux Falls Fire Rescue, he provides us with helpful tips on creating an updated public access defibrillation (PAD) program. Tell us about your medical background. What job position do you currently hold? My medical background started as an Emergency Medical Technician. I am also a Registered Nurse with a Master’s of Science degree in Nursing as a Clinical Nurse Specialist (CNS). I worked in a busy critical care burn unit on my days off as a firefighter before taking my current role as the EMS Division Chief for Sioux Falls Fire Rescue, where I oversee our medical programs. I also received a Fellowship at Harvard University in governmental studies. In addition, I have presented at several major conferences, including the 18th Annual World Conference on Disaster Management, the National Association of EMS Physicians Conference, and the Pan-American Healthcare Delivery and Disaster Management Conference in Suriname, South America. Tell us about the public access defibrillation (PAD) program in Sioux Falls, South Dakota. When and why was it created? It was started in 2003 with the goal of decreasing the time to get a defibrillator to the patient’s side during a cardiac arrest. Studies show that for each minute a patient is in cardiac arrest, their survivability decreases ten percent. When taking into account how long it takes to get EMS crews to the patient, it is surprising to find out how long it actually takes (calling 911, processing the call, alerting crews, travel time, getting to the patient, and powering up a defibrillator). To increase patient survivability, I wanted to get a defibrillator to the patient in under three minutes; that would allow bystanders to use a simple defibrillator (PAD) to shock the patient as soon as possible, and then responding trained personnel from fire and EMS can take over. Initially, we started with 20 PADs. The program has now grown to over 800 PADs, and we have an additional 250 organizations on a waiting list for the next arrival of PADs. How have PAD programs evolved over the years? What changes have you had to make to your program over the years in order to keep it updated? PAD programs have evolved in a couple of areas. Most importantly, the concerns with liability with using a PAD have been almost eliminated. In some cases, lawsuits have occurred because a PAD was not available. This will be something that will be a growing concern as the working population begins to age, and also as the expectation grows that every location will have a PAD. The second major evolution is of the PAD itself. When they first became available, defibrillators required some training for use and were a little intimidating. However, rhe new generations of PADs have become so simple to use, that it is very common to hear that someone who had never seen a PAD before was able to successfully use it to save a life. We even tested PAD training with fifth graders, and they found it to be very easy to learn, so we now have the PADs in all of our schools. In fact, we have saved two high school students who were defibrillated by fellow students using a PAD. What are the main components of a good PAD program? There are five components to a good program: the PAD itself, medical direction and a program coordinator, training, and EMS integration. PAD. One needs to determine the device they wish to use for their program. We use only one device, which makes training, servicing, and upgrading easier. We had tested several PADs with various user groups to determine ease of implementation. We also wanted to make sure that our PAD would integrate with the same technology used by responding medical providers. Therefore, we selected the Medtronic Physio-Control CR+ unit for our public access defibrillator and use the Medtronic Physio-Control LIFEPAK® 12 for our medical responders. Medical Direction. Ensuring that there is medical oversight is important to a PAD program. This oversight will depend on state laws. In South Dakota, medical oversight must be provided by a physician. Often, some companies that manufacture the PAD may have a physician in your area to help oversee a PAD program. Medical direction helps ensure the quality of patient care is maintained throughout the continuum of care. A physician will help bring leadership, authority and medical expertise to the PAD program and ensure that rescuers are properly trained and that skills are maintained. The physician is also responsible for incident review each time a PAD is used. PAD Coordinator. Typically, someone in an organization such as a fire department is needed to oversee the PAD program. This person is responsible for the day-to-day activities associated with the PAD program. They ensure AED maintenance checks, and are responsible for inventory and reordering supplies. The coordinator also oversees the scheduling of training and retraining for CPR/PADs. Finally, they are responsible for all aspects of PAD event review following use of the device. The extent of responsibility of the PAD Coordinator is determined by the PAD oversight physician. Training. This includes training for the PAD as well as CPR training. We regularly train over 2,500 people every year in CPR, and that training includes the use of the PAD. Training is a critical component of a successful PAD program. It helps to alleviate panic and teaches the responder how to identify an emergency. Training gives responders the confidence to act, and that is key to making people take action. EMS Integration. This is an imperative and required part of PAD programs. The entire design of the program needs to keep the goal of patient survival at the forefront. For our program, we ensured system-wide compatibility by making sure our PADs were from the same manufacturer as the defibrillators used by fire and EMS. In fact, the electrodes with our PADs can be used with the units from responding fire and EMS units. This ensures a seamless integration of cardiac care and defibrillation technology, the best patient care, and hopefully, a successful outcome. We have also integrated the 911 Communication Center into our program. This allows the addresses where PADs are located to be marked with an alert, allowing the 911 dispatchers to know where a PAD is located at the site of an emergency. Dispatchers can assist with AED instructions if necessary, and can also notify local EMS units if an AED has been used or is present. Who can start a PAD program? How can someone find the right funding to begin a PAD program? Anyone can start a PAD program, but it does help to have some type of medical background. This offers some insight into the importance of PAD programs. One needs to be able to understand the technology, rationalize for the intervention, and know the importance of rapid deployment of a PAD. Having the understanding of what it takes to save patients in cardiac arrest (i.e., rapid cardiac defibrillation) helps give someone the passion to do whatever it takes to get the program moving. Being able to “talk the talk” to corporate heads will help open doors for funding. Remember, one person cannot make this a success alone. It takes many people to create a successful PAD program. The person spearheading the program must know this and bring everyone to the table. One way to find funding is to bring all the stakeholders together to understand the complete “chain of survival” for offering patients the best opportunity to survive an out-of-hospital cardiac arrest. The stakeholders include EMS, Fire, Police, 911 Operations, hospitals, cardiologists, the American Heart Association, the state Medical Association, and anyone else who has an interest in cardiac survival. When each group understands the importance of the PAD program, members will start looking for funding options. There are a number of places in which to begin looking for funding. Once we started, we learned there was some funding for a startup program from the United Way. It was enough to start the momentum of the program. We took this funding, and rather than dole it out, we offered a “matching grant.” This required those interested in getting a PAD a 50% match, because it creates more ownership in the program. This matching grant also allows the initial funding to go further. We also were able to gain support from the Avera Heart Hospital of South Dakota, and their CEO Jon Soderholm. He was very instrumental in helping us negotiate further purchases of PADs as well as allowing his staff to assist our program. We have developed a very successful relationship with the Avera Heart Hospital of South Dakota, and in fact, use their tracking system to track all our PADs. We can also purchase larger quantities of PADs and use the hospital storage area to secure them. It is partnerships like these that can result from bringing the stakeholders together at the onset of the planning. How can one determine how many AEDs are needed in a public space? What areas do you recommend have an AED? Where are the best places they should be located? We determined that the optimum time to get a PAD to the patient was under three minutes. Once this was determined, locations could then have sites do walk tests for placement. A rough rule of thumb is a PAD every 100 meters or 300 feet. We also suggest a PAD on every other floor of a building. In particular, we suggest placing them in a common location such as a lobby, and next to elevators. Locations that would benefit from a PAD would be sites where a large number of people would be located; this includes churches, schools, auditoriums, sporting or event stadiums, workout centers, large businesses, apartment complexes, and high-rise buildings. Other sites would be shopping centers, golf courses, large warehouses, airports, marinas, and factories. What resources are available for AED training? The American Heart Association’s CPR training program offers a component to train in the use of a PAD. Any AHA CPR instructor should be able to provide the training. Some include a training DVD/CD, which provides how to use the PAD and other important points. From what we have seen, it is often the person who has never seen a PAD that has to put it into use, and does so successfully. We often stress to people not to be afraid to use this device, since it will not shock a person who does not need defibrillation. Why is it important to coordinate with EMS when creating a PAD program? There are several reasons. The first is to ensure that the technology of the PAD is the same as what is being used by EMS. There are various proprietary technologies used by various manufacturers of PADs and defibrillators, and many have differences in whether they are biphasic vs. monophasic, their energy delivery, escalating energy, waveform patterns, PAD placement, etc. Ensuring similar defibrillator technology from start to finish offers patients the best opportunity for survival. Another reason is so that EMS responders are familiar with the PADs and their capabilities. We selected our PADs to integrate with those used by EMS; this has even allowed EMS to disconnect the electrodes from the PAD and connect directly to their defibrillator, which saves time and decreases waste of supplies. Updating the responding EMS units that a PAD is being used on a patient is important information. They know the patient may have already been defibrillated and therefore may be working on a patient with a greater probability of survival. My last point is about the 911 Call Centers. When someone calls 911 with an emergency, the address and phone number of the caller automatically displays on the screen in front of the 911 dispatcher. However, we have also now added the location of every PAD into the database for 911, so whenever there is a PAD at the location of the caller, a small heart is displayed on the dispatcher’s screen. Therefore, if the call is about a cardiac arrest, the dispatcher can notify the caller about the PAD location and provide instructions for use. Often, the caller may not know there is a PAD, so linking this information is vital for saving time. What are some of the things each recipient receiving a PAD should be informed of? We provide them with a contract that they sign. The contract asks for their contact information, and requires that they check the device monthly and that they are responsible for replacing batteries. We also provide them with a training DVD, a window sticker for the front door, and a wall cabinet so that the unit can be mounted on the wall. We require they notify us of the location within the building where the PAD will be located, so this can be put into the 911 database. What roadblocks can be expected? For example, do state or local ordinances usually cause a delay? Some roadblocks are the concerns that having the device could put an agency at risk if it is improperly used. In reality, I feel that in the near future it will be a greater risk if there is not a PAD at the location. We have one large banking operation with over 1,000 workers that will not put in a PAD because of their concern for liability. However, there are more than enough agencies that want a PAD. In some cases, getting a physician to provide the oversight can be a challenge. Most states require physician oversight. I would suggest using the EMS Medical Director or a cardiologist from a local hospital; they can also be the spokesperson and offer that level of creditability to the program. There are not a lot of local ordinances regarding PAD programs; however, I think this will change in the near future. I would expect future changes to include required PADs in high-rise apartments and facilities where there are large numbers of people. Where can people turn for more help or to answer questions? If anyone has questions, they can contact me and I will gladly offer any insights or advice. I can be reached at “jsideras@siouxfalls.org” or at (605) 367-8076.