In memoriam Dr Jeff Wassertheil founding director of the Cardiac Arrest Survival Foundation

In Australia sudden cardiac arrest (SCA) is a leading cause of death.  Yet the precise number of people who die from SCA is not known, the nearest estimates ranging from 23,000 to 33,000 deaths per year.  Prompt defibrillation increases the probability that people have of surviving a cardiac arrest away from a hospital.  However, owing to ambulance response times, especially in built-up metropolitan areas, by the time that emergency defibrillation arrives it may be too late to save the victim as for every minute lost the chance of survival diminishes so that after ten minutes, in all probability, the SCA victim will die.  Consequently, having a wide distribution of AEDs (automated external defibrillators) available for employees at workplaces and the public in general is essential to saving lives. 

Inspired by the late Dr Jeff Wassertheil, a founding director, the Cardiac Arrest Survival Foundation (the Foundation) embarks on various research projects related to cardiac arrest:  The first of these is to establish the National Cardiac Arrest Registry (NCAR) to determine the precise number of people who die from SCA.  The ultimate goal of NCAR is to assist government, corporate and ambulance service administrators identify:

• Who is affected.

• When and where cardiac arrests occur

• Which elements of the emergency health services system are functioning well and those that are not.

• How changes can be made to improve cardiac arrest outcomes.

Based on this information another goal is to promote government sponsored public access to defibrillation (PAD) programs.  Even though perhaps more than 30,000 people die from sudden cardiac arrest every year in Australia there is scant distribution of defibrillators either at the workplace or in public places.  In Australia the first longitudinal study conducted by Wassertheil, Keane, Fisher and Leditschke, of events at the Melbourne Cricket Ground and the Shrine of Remembrance between 1989 and 1997 supports the value of PAD:

Twenty-eight cardiac arrests occurred between December 1989 and January 1998.  Of these, 25 episodes were situated at the MCG and three at the Shrine of Remembrance.  The incidence of cardiac arrest at the MCG site was 1 in 500 000 patron admissions.  Of the 28 patients, 24 (85.7%) were successfully resuscitated at the venue.  Subsequently, 20 (71.4%) were discharged home from hospital.  Age ranged from 23 to 83 years.  CPR was commenced on 26 patients (92.1%) within 2 minutes of the time of documented collapse.  The two cases where CPR was delayed occurred in the MCG Stadium car park prior to the commencement of the event and before amalgamation of equipment and deployment of personnel (Wassertheil et al; 2000, p. 97).

Notwithstanding that this study is more than ten years old, unlike in the USA where in 2000 the Clinton administration legislated for compulsory access to defibrillation in all federal buildings, in Australia federal governments have paid scant attention to PAD.  Other than the PAD program in Australia sponsored by the Federal Department of Health and Ageing between 2005 and 2008 for which 147 AEDs were deployed none of Australia’s state and territorial governments have seen fit to deploy public access defibrillators.  Another issue related to the Department of Health and Ageing PAD deployment is the reliability of the 147 defibrillators deployed because of an uncertain maintenance and repair schedule (see Dingsdag, 2009).  Dingsdag’s article reflects a longitudinal study conducted in the Journal, American Medical Association, (Shah and Maisel, 2006), which suggests that in Australia too more than 20 % of defibrillators may not work when needed in an SCA event. 

Because the number of AEDs deployed and their reliability rates are unknown, another objective of the Foundation is to find out locations of AEDs, their age, their condition, how and when they are maintained and whether they are monitored or not.  In order to minimise out of hospital sudden cardiac arrests in Australia a twin deployment model of maintained, remotely monitored AEDs in public areas and workplaces is recommended by the Foundation.  Deployments should be supplemented with an adequate cohort of trained first responders (ten per AED), particularly in workplaces where first aiders can be more easily identified.  However, in situations where only untrained bystanders are available these people can successfully apply defibrillation therapy owing to the electronic prompts and ‘smart systems’ of contemporary defibrillators which analyse the victim’s heart status and instruct them how to proceed even in the event where no shock is required.  A comprehensive Federal Government publicity campaign publicising the failsafe capacity of most contemporary AEDs would contribute to alleviate the hesitancy of untrained bystanders to deploy and apply them to SCA victims.  Further, in the interest of enhancing SCA survival rates each government of Australia’s nine jurisdictions should comprehensively publicise that ‘Good Samaritan’ legislation protects all SCA responders from litigation should the rescue attempt fail.  

For the workplace in particular the Foundation strongly urges the Federal Government to adopt another USA initiative, the Occupational Safety and Health Administration’s (OSHA) Best Practices Guide: Fundamentals of a Workplace First-Aid Program, a guide to help employers and employees develop workplace first aid programs which include AED training if an AED is available at the workplace.  OSHA claims that:

All worksites are potential candidates for AED programs because of the possibility of SCA and the need for timely defibrillation.  Each workplace should assess its own requirements for an AED program as part of its first-aid response (OSHA; 2006, p.10).

According to OSHA every first-aid training program should be designed or adapted for specific workplaces (in accordance with the specific hazard context of each workplace) and may include first-aid instruction in the following:

• Establishing responsiveness;

• Establishing and maintaining an open and clear airway;

• Performing rescue breathing;

• Treating airway obstruction in a conscious victim;

• Performing CPR;

• Using an AED; (OSHA; 2006, p.13).

This is a strategy that should be taken up as part of employer due diligence of the proposed Safe Work Australia Act contemplated under the national harmonisation of OHS legislation process.

References

Dingsdag, D. 2009 ‘Reliability, sustainability and effectiveness of automated external defibrillators deployed in workplaces and public areas,’ The Journal of Occupational Health and Safety, Australia, New Zealand, October, Vol. 25 (5). pp. 351 - 361.

OSHA, 2006,Best Practices Guide: Fundamentals of a Workplace First-Aid Program, OSHA 3317-06N.

Shah, J. S., Maisel, W.H., 2006, ‘Recalls and Safety Alerts Affecting Automated External Defibrillators,’ Journal, American Medical Association, August 9, Vol. 296, No. 6, 655-660.

Wassertheil, J. Keane, G. Fisher, N. and J. F. Leditschke, 2000, ‘Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy-a forerunner to public access defibrillation,’ Resuscitiation, Volume 44, Issue 2, April.