6 December AEDs in New Zealand Workplaces and Communities St John Submission to the Health Select Committee

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1 AEDs in New Zealand Workplaces and Communities St John Submission to the Health Select Committee

2 Contents Executive Summary 2 Introduction 3 Conflict of interest statement 3 Cardiac arrest and 3 defibrillation The chain of survival 3 Cardiac arrest in New Zealand 4 The role of AEDs in improving survival 5 from cardiac arrest AEDs in communities and workplaces in 6 New Zealand The role of a database of AEDs in the 8 community Summary 8 References 8 About St John 9 Page 1

3 1. Executive Summary 1.1 St John is committed to improving outcomes from cardiac arrest in New Zealand. 1.2 Survival from cardiac arrest is dependent on a number of factors summarised by the chain of survival (a series of links that can improve the outcome of cardiac arrest). 1.3 The most important aspects of the chain of survival are CPR (Cardio Pulmonary Resuscitation) prior to an ambulance arriving (bystander CPR) and early use of a defibrillator. 1.4 Bystander CPR rates appear to be falling in New Zealand. We believe the best way to reverse this trend is to incorporate CPR training into the education curriculum. 1.5 Use of an automated external defibrillator (AED) prior to an ambulance arriving increases the chance of a person surviving cardiac arrest from approximately 7% to approximately 30%. 1.6 AEDs are safe and easy to use with a minimum of training. 1.7 There is clear evidence that AEDs are very effective in areas where there are large numbers of people for example, airports, casinos, malls. 1.8 It is unclear what role AEDs have in areas where there are smaller numbers of people. As an example a workplace with fifty people working a normal week can expect, on average, one cardiac arrest every 222 years. 1.9 The workplace example in 1.8 could have an AED on site at a cost of approximately $320 a year In communities without identified areas of large numbers of people, the best way to reduce time to defibrillation is through the use of first responders who take an AED to the scene of cardiac arrest A national database of the location of AEDs in the community will have some benefit. This benefit will be small, unless it can be used to identify AEDs close to the scene of cardiac arrest, allowing people to be contacted to take the AED to the cardiac arrest. The issues here are complex, but we are committed to resolving them % of cardiac arrests occur in the home. If we are to improve outcomes from cardiac arrest in New Zealand we must focus on all aspects of the chain of survival for all cardiac arrests. St John aims to do just that, with our Heartsafe Program which we are launching Page 2

4 2. Introduction St John is pleased to provide a submission on the petition asking that: The House of Representatives ensures that there is ready access to automated external defibrillators and training in all communities and workplaces. St John has substantial experience with out of hospital cardiac arrest, providing an ambulance service to over 85% of New Zealanders. We are New Zealand s leading provider of first aid and Cardio Pulmonary Resuscitation (CPR) training, including training in the use of automated external defibrillators (AEDs). 2.1 Conflict of interest statement St John provides commercial CPR courses and sells automated external defibrillators (AEDs). The income that St John makes from these products is used to support our ambulance service and other community services. 2.2 Cardiac arrest and defibrillation A cardiac arrest occurs when the heart stops pumping blood. In adults the most common cause of cardiac arrest is a heart problem causing the normal flow of electricity to be disrupted. This electrical disruption is called ventricular fibrillation. The treatment for ventricular fibrillation is to provide a controlled electric shock to the heart using a defibrillator. Traditionally defibrillators required the person using it to have a significant level of training and knowledge. AEDs are defibrillators that automatically determine whether or not a shock should be delivered to the heart, and then deliver that shock. Most AEDs use voice prompts to tell the person what to do. AEDs are safe, easy to use and can be used with a minimal amount of training. 2.3 The chain of survival Whether or not a person survives a cardiac arrest is determined by a number of factors that all add up together. These factors are known as the chain of survival. The links in the chain of survival are: 1. Early recognition. Recognising cardiac arrest or cardiac chest pain (the most common warning symptom prior to cardiac arrest) early. 2. Early call to the ambulance service. Calling ambulance services early reduces the time it takes for an ambulance to reach the patient. 3. CPR. CPR improves the chance of survival by keeping blood flowing to the brain and heart whilst attempts are made to restart the heart. 4. Defibrillation. Attaching and using a defibrillator as early as possible reduces the time it takes to re-start the heart. 5. Advanced cardiac life support. Skills provided by highly trained ambulance officers further increase the chance of survival. Page 3

5 6. Post resuscitation care. A high level of care following a cardiac arrest further increases the chance of survival. Although each link contributes to the overall chance that a person will survive, the most important links are CPR and early defibrillation. Survival is highest when CPR is combined with early (within five minutes) use of a defibrillator. 2.4 Cardiac arrest in New Zealand There are approximately 1500 primary cardiac arrests (that is due to a heart problem) outside of hospital in New Zealand each year. This equates to approximately one primary cardiac arrest per 3000 people per year The average age of people having a cardiac arrest is 65 and 70% are male 80% of cardiac arrests occur in a private home. Thus approximately 300 cardiac arrests occur in New Zealand each year outside of private homes We do not have national data on the number of patients in cardiac arrest that receive CPR (the bystander CPR rate) prior to an ambulance arriving. Auckland data from 2002 demonstrated a bystander CPR rate of 55%. Recent pilot data suggests our bystander CPR rate is approximately 45%. Our observation is that overall, bystander CPR rates are falling within New Zealand. We believe that the key to reversing this trend is to formally incorporate CPR training into the New Zealand education curriculum On average, in New Zealand it will take approximately twelve minutes for ambulance officers to get to a patient in cardiac arrest and attach and use a defibrillator. This time can be potentially reduced by members of the public using an AED prior to an ambulance arriving We do not have national survival data for out of hospital cardiac arrest in New Zealand. Pilot data suggests that our cardiac arrest survival rate is approximately 7%. Around the world survival rates have been reported as low as 2% and as high as 20%. Page 4

6 3. The role of AEDs in improving survival from cardiac arrest The use of AEDs by the public prior to ambulance arrival is well established in New Zealand and around the world. This is often referred to as public access defibrillation (PAD). In general there are two models: 1. AEDs are available (on a wall or in a cabinet) to any member of the public walking past, similar to the availability of fire extinguishers. The site of the AED is usually well marked. Such a system is common in many airports in the world and in Japan where there is approximately one AED per square kilometer. Elsewhere in the world the model of making AEDs available to the public outside of a tightly monitored environment (like an airport) has been associated with a relatively high rate of the defibrillator being stolen or damaged. 2. AEDs are taken to the cardiac arrest by people specifically identified to do so for example security guards in a casino, first aid providers at large sporting events or community first responders in small rural communities. Just how much survival can be improved by the use of AEDs by the public prior to an ambulance arriving is unclear. There are reports in the literature of relatively high survival rates for example from Chicago Airport 1 where the survival rate was 52%. This study however reports only a small number of cardiac arrests. Two larger studies indicate that a more realistic expectation is that AED use prior to ambulance arrival is associated with survival rates of approximately 30%. In a large randomized trial from USA sites with large numbers of people (e.g. shopping malls) were randomly allocated to 1) have first responders perform CPR and call an ambulance or 2) have first responders perform CPR, call an ambulance and use an AED. The sites with an AED had survival rates of 23.4% and those without had survival rates of 14%. In a large observational study from Japan 3 use of an AED prior to ambulance arrival was associated with a survival rate of 38%. Thus, it would appear that AED use by the public prior to an ambulance arriving improves survival from approximately 7% to approximately 30%. This means that the number needed to treat (the NNT or the additional number of patients who need to receive the treatment in order to save the life of one patient) is 4.3. In relative terms this number is much lower than the NNT for many other treatments for example the NNT for clot busting drugs in heart attack from a blocked artery is approximately 25. Page 5

7 4. AEDs in communities and workplaces in New Zealand There is good evidence for AEDs in areas with high numbers of people for example, airports, casinos, shopping malls and large workplaces. As the number of people in an area falls, so does the chance of a cardiac arrest happening in that area. It is not clear where the cut off point is that is, it is not clear when an area contains too few people to make it worthwhile to have an AED present. From our primary cardiac arrest rate of 1/3000 people per year we can expect one primary cardiac arrest per 26 million people hours. That is, if one million people were together for 26 hours we would expect (on average) one primary cardiac arrest to occur during that time. This allows us to calculate the expected cardiac arrest rate in a workplace. For example: A workplace has fifty people at work for nine hours a day for five days a week. This means that there are 117,000 people hours in that workplace per year This means we would expect (on average) one cardiac arrest in that workplace every 222 years. It is possible to estimate the cost to that workplace of having an AED: The average cost of an AED is $3600 The average AED will last fifteen years before having to be replaced The AED battery needs to be replaced every five years at a cost of approximately $250 The AED pads need to be replaced every five years at a cost of approximately $150 This equates to a total cost of $320 a year That workplace can expect (on average) a cardiac arrest every 222 years and thus the cost to have an AED present for that cardiac arrest is $71,000 The number needed to treat (NNT) in order to get one additional survivor is 4.3 thus the total cost per additional survivor is $303,300. This might sound expensive but it is less then the cost per additional survivor from some other treatments available in New Zealand. The cost per additional survivor is substantially less when that same AED covers a larger population of people hours. This can be accomplished by: Having a higher cut off point or Having first responders who respond within their community to the scene of a cardiac arrest with an AED or Page 6

8 Having an arrangement with the people in that workplace that they are prepared to respond outside their workplace to a cardiac arrest, taking their AED with them. Page 7

9 5. The role of a database of AEDs in the community We have plans to develop a national database of AEDs present in the community in New Zealand. This will help us: Identify that an AED is on site at a cardiac arrest and enable us to prompt the caller to get and use the AED and to Identify that an AED is nearby (but not on-site), then phoning to ask someone to take it to the scene of the cardiac arrest. This is not a simple task there needs to be a clearly established plan of whether or not they will respond (not everyone will be prepared to do so), who to phone, who will respond, how far they are prepared to go and who is responsible for them while they do so. It is not a simple process to put this in place, but we are working through the complexities. 6. Summary 6.1 Only 20% of cardiac arrests occur outside peoples homes. 6.2 To improve outcomes from cardiac arrest in New Zealand we believe that focus needs to be on all aspects of the chain of survival for all cardiac arrests. 6.3 AEDs have a place in the community and large workplaces, and we believe AEDs are best deplaoyed as part of a programme including CPR training. 6.4 St John will launch a Heart Safe Program in 2011 which aims to work with communities within New Zealand on all aspects of the chain of survival within the community. References 1. Public use of automated external defibrillators. Caffey et al. NEJM, 2002; 347: Public access defibrillation and survival after out of hospital cardiac arrest. The public access defibrillation trial investigators. NEJM, 2004; 351: Nationwide public access defibrillation in Japan. Kitamura et al. NEJM, 2010; 362: Page 8

10 About St John A community-based charitable organisation Has provided ambulance services in New Zealand since 1885 and now delivers to over 85% of the population The foremost provider of training in first aid and pre-hospital emergency care, training over 90,000 students in Provides emergency care and first aid cover at more than 9,500 public events each year Provides a range of community care programmes nationally, all of which support the Government s strategies for health. These services are funded and resourced by volunteers Has a growing youth programme where young New Zealanders (from six to 18 years) learn first aid, self-discipline and general life skills in their communities. Some key statistics describing our size, shape and work from Patients treated by ambulance officers 371,224 Number of emergency incidents attended 309,051 Total number of ambulance and operational vehicles 601 Kilometres travelled by ambulances 17.2 million Ambulance stations 193 Number of volunteers 8,045 Number of paid staff 2,320 Number of youth members 5,714 Total membership 16,079 Page 9

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