Occupational health adviser Alison Keemar makes the case for why having automated external defibrillators available in the workplace can help save lives.
A recent literature review was unable to secure any published research papers on the topic of automated external defibrillators (AEDs) in the workplace, or any data to support or repudiate the success or failure rate of the use of them in a public place. Nevertheless, there is strong evidence that having AEDs available at work and in public spaces saves lives and can limit an organisation’s liability. However, there is no guarantee that employees trained to use AEDs will remember how to use them in a cardiac emergency, so regular training, practice and support must be given to staff to keep skills up to date.
According to Descatha and Baer (2008), evidence from the European Resuscitation Council firmly upholds the theory that the use of AEDs in the management of sudden cardiac arrest outside of a hospital setting strongly improves a victim’s chance of survival. The question we must now ask is: why are there still so few AEDs present in workplace and public settings in the UK?
Helping save lives
Heart disease is one of the UK’s greatest killers, with British Heart Foundation (BHF) statistics estimating that more than 60,000 sudden cardiac arrests take place each year outside of a hospital environment. According to Wood (2007), this amounts to approximately 74% of the total cardiac arrests in the UK.
However, there is still much debate surrounding sudden cardiac arrests in workplace settings. Beacham (2012) is of the opinion that sudden cardiac arrest in a workplace setting is no different than any other medical emergency and that sufferers should be dealt with by the emergency services and no one else. Wood disagrees, arguing that in many cases the emergency services can take too long to arrive, resulting in the loss of a life that may have been saved if a defibrillator had been used.
The UK Resuscitation Council (2010) and the BHF (2012) support community-based, public-access defibrillators (cPAD). However, Arnold (2007) points out that a defibrillator must not be considered to be a replacement for cardiopulmonary resuscitation (CPR), but instead should be viewed as an integral part of the survival chain for patients who experience sudden cardiac arrest. This is corroborated by Starr (2012), whose considerable research into post-cardiac arrest survival rates concludes that early life support CPR must be the first sequential intervention – although Pell et al (2002) argue that this suggestion is too simplistic, because of the complexity of forces involved in the survival of sudden cardiac arrest.
Making AEDs effective in the workplace
There appears to have been limited qualitative or quantitative research carried out to support the introduction of AEDs in the workplace. Descatha and Baer suggest that this may be because statistically very few sudden cardiac arrests actually happen in a workplace setting. Wood, however, argues that the demographic profile of a workplace population is likely to be a younger age group, thus resulting in a substantial number of life years saved per case.
This may be changing, however, with Osborn (2013) pointing to recent changes in UK employment law that will result in an increase in the number of older workers, many of whom will have the increased risk factors associated with coronary heart disease. Regardless of these facts, a recent survey by the Institution of Occupational Safety and Health (IOSH) found that more than half of 1,000 UK businesses did not have an AED available on their premises.
There has been disagreement about who should use an AED and around the requirements for training. There appears to be a consensus that the effective use of a manual defibrillator requires the operator to have significant knowledge, training and accountability for the decision-making process involved (Liddel et al, 2003; Descatha and Baer, 2008), and that their use in the workplace is limited (Starr, 2012). This has led, in recent years, to the development of semi-automated and automated machines, which now instruct the operator if and when a shock is required (Arnold, 2007), with totally automated machines now frequently being used in workplaces and public settings (Beacham, 2012).
Ease of use
As AEDs are now so easy to use, Descatha and Baer report that some manufacturers advise that training is "optional". Beacham says that if AEDs are considered to be so intrinsically safe to use, “why bother training operators at all?” Arnold, on the other hand, warns that employers have a duty of care to employees and that it would be unwise to contradict recommendations made by the UK Resuscitation Council – especially when doing so may put employers at risk of an investigation by the Health and Safety Executive.
The continued increase in the introduction of cPAD machines in the wider community has also necessitated a change in theory and viewpoint on the training debate (Beacham, 2012). This has led to changes in guidelines from the UK Resuscitation Council, which states that although it encourages training, it believes that AEDs can be used safely and effectively by an untrained person and that the use of an AED should “not be restricted to a trained rescuer”.
Assessing the cost
The cost effectiveness of employer-funded AEDs has been debated, with Descatha and Baer suggesting that businesses carefully assess their risk requirements, conduct adequate consultation with relevant stakeholders and ensure that a robust defibrillator programme is established and in place before AEDs are installed. They suggest that because of the rarity of sudden cardiac arrest in workplace settings compared with other occupational health issues, funding may be better spent on different initiatives. The cost and issues relating to maintenance of equipment and the prevention of vandalism is well recognised (Pell et al, 2002). Arnold, however, argues that employers must be careful not to be accused of putting money or inconvenience above the cost of a life.
IOSH (2013) suggests that companies should consider the effects on staff of losing a colleague, as well as the potential cost of lost productivity and the replacement and training of staff. Arnold also points out that there are underlying indirect costs to a business of a sudden cardiac arrest taking place on the premises, including the effect on customers or members of the public who have witnessed the event and the possibility of adverse publicity.
Beacham recognises that the use of an AED, especially in the case of a fatality, can result in the operator suffering from psychological distress, which may possibly lead to post-traumatic stress disorder. It is recommended that post-incident counselling is factored into any employer-sponsored AED programme (Starr, 2012; Wood 2007).
The law and AEDs
To date, UK law does not have any statutory legal obligation for employers to provide AEDs. Nevertheless, their installation in a workplace setting would assist in compliance with the Management of Health and Safety at Work Regulations 1999, which instructs employers to “make such arrangements as are appropriate in preventative and protective measures” and to consider the guidance outlined in the Health and Safety (First-Aid) Regulations 1981 that encourages employers to focus on the nature, diversity, hazards and risk of the work carried out by employees (Wood, 2007).
Osborne states that no civil law cases have yet been brought against UK employers for failing to provide AEDs; however, it is considered only a matter of time before a first test case will present itself. In addition, the UK Resuscitation Council points out that regardless of there being no statutory law, common law may invoke liability for failure to take satisfactory preventative measures to protect employees and members of the public in a workplace environment.
In comparison, in 2000 the US passed federal legislation to authorise the availability of government grants to place AEDs in any public place that a sudden cardiac arrest was likely to occur and strongly advised private organisations to install them in all workplaces (Starr, 2012).
Improving survival rates
Torres (2008) says that regardless of the fact that AEDs are becoming more common in UK workplaces, there is confusion about their use. Osborn adds that first aiders, employees and in some cases managers may often have concerns around their own personal and corporate responsibility when AEDs are used. Descatha and Baer propose that many of these issues can be overcome by effective communication with all parties throughout the development phase of an AED programme and by ensuring that the programme has management backing.
Osborn warns that to draw the conclusion that AEDs are not required if a location is close to a hospital or an ambulance station is unwise. Statistical evidence from resuscitation councils in both the UK and the US shows that having access to an AED in the first couple of minutes after cardiac arrest improves a patient’s chances of survival and decreases morbidity and mortality (Wood, 2007).
The UK Resuscitation Council says that the probability of the heart rhythm being amended by defibrillation decreases by between 7% and 10% for each minute that passes without action. The BHF supports this, but also advises that CPR given immediately following sudden cardiac arrest is the most important intervention as it buys the patient valuable time for further help to arrive and triples the chance of survival.
The UK Resuscitation Council agrees with this, reporting evidence that a correct and timely response by a bystander in any sudden cardiac arrest situation has a huge positive impact as part of the chain of survival. Starr corroborates this, citing evidence from the US that shows that immediate bystander CPR, early defibrillation and effective post-resuscitation care can achieve survival rates following out-of-hospital sudden cardiac arrests of more than 50%.
AEDs must have appropriate management
There appears to be a consensus of opinion that recognises best practice in the development of an AED programme, including the establishment of a management system. Torres says that employers must create management policies that clearly define the roles and responsibilities of those people who oversee and monitor an AED programme. Starr agrees, adding that it is essential that a qualified medical practitioner, preferably a doctor, be assigned to oversee all medical aspects of AED use. This includes conducting a detailed investigation, review and report each time an AED is used.
Wood warns that employers could leave themselves liable to prosecution if they do not take the time to incorporate a management policy as the basis of their AED programme. Descatha and Baer cite examples of this, such as an AED not working when it is needed because of dead batteries or the storage of an AED machine in a locked cabinet, which meant that it was inaccessible to a responder when needed. Torres says that if an employer is going to implement an AED programme, it must make sure it is appropriate and effective, including evidence that it has identified and managed risk and that the introduction of a workplace AED will be of potential benefit to its employees. She adds that employers often implement an inferior programme, thus placing themselves at a greater risk of liability than if they had no programme at all.
There is a general assumption that once responders are trained to use an AED they will be able to recall these skills if needed (Arnold, 2007). Torres points out that skills will deteriorate over time and that best practice should be for employers to carry out regular drills for their response teams. Liddel et al corroborate this by suggesting that the more practice responders have with given scenarios, the readier they will be to use their skills in earnest in the attempt to save a life.
In conclusion, it is apparent that AEDs have become inexpensive, easy-to-use devices that could increase the survival rate of a victim of sudden cardiac arrest.
The development of an AED programme, including the decision to install and use AEDs in a workplace setting, demonstrates a rational, apposite acknowledgement from UK employers of their duty of care towards employees in the management of a sudden cardiac arrest.
Simply purchasing and installing AEDs is not, however, the end of a life-saving programme. There is no guarantee that responders will remember how to use an AED in a cardiac emergency and therefore regular training, practice and support must be given in order to ensure that essential skills are not lost. The implementation of an AED programme could ensure that an organisation protects its workforce, limits liability and saves lives.
The general consensus of the literature in this review is that the greatest risk an employer could take is not to have an AED programme.
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