The Right Place at the Right Time
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 12 Linguagem: Inglês
10.1161/circulationaha.117.027305
ISSN1524-4539
AutoresMichael E. Field, Richard L. Page,
Tópico(s)Trauma and Emergency Care Studies
ResumoHomeCirculationVol. 135, No. 12The Right Place at the Right Time Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBThe Right Place at the Right TimeOptimizing Automated External Defibrillator Placement in the Community Michael E. Field, MD and Richard L. Page, MD Michael E. FieldMichael E. Field From Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison. and Richard L. PageRichard L. Page From Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison. Originally published21 Mar 2017https://doi.org/10.1161/CIRCULATIONAHA.117.027305Circulation. 2017;135:1120–1122Article, see p 1104Out-of-hospital cardiac arrest (OHCA) afflicts >350 000 persons annually in the United States.1 Although early defibrillation can improve survival, public access defibrillation (PAD) with an automated external defibrillator (AED) is not available much of the time.2 The American Heart Association has long advocated for the development of PAD programs,3 with the AED as a crucial component of the "Chain of Survival."4 Early proof-of-concept studies in controlled environments, such as aircraft and casinos, demonstrated efficacy and confirmed the importance of early defibrillation.5,6 In the PAD trial, the survival rate doubled in higher-risk public settings when lay responders trained in cardiopulmonary resuscitation were equipped with AEDs compared with those who were not.7 Despite data confirming efficacy of early defibrillation, AED usage remains low.2 This finding relates, in part, to an issue of limited resources because there is a cost related to AED purchase, placement, and maintenance.One of the challenges for PAD programs has been deciding where to place AEDs to optimize access. Early efforts focused on identifying sites or location categories with high OHCA incidence rates. For example, Becker and colleagues8 identified 10 location categories with a higher incidence of cardiac arrest in Seattle and King County, Washington; these locations included the airport, county jail, and a large shopping mall. They estimated that coverage for 134 cardiac arrest patients over a 5-year period could be obtained by the placement of 276 AEDs in the 172 highest incidence sites. However, to cover the remaining 347 arrests over this same time period, an AED would have to be placed in an additional 71 000 sites, illustrating the challenges of obtaining widespread coverage. The PAD trial, in addition to demonstrating improved survival with the AED, provided further understanding of the frequency of OHCA in reporting the highest frequency (among the population units studied) at fitness centers and golf courses. AEDs have been shown to be safe and effective in improving survival from OHCA in a variety of public settings.9 State and federal legislation has resulted in AEDs being placed in many locations, such as aircraft, fitness centers, and federal buildings. Grassroot efforts and community action have resulted in placement in some locations, such as churches and schools, despite a relatively low frequency of OHCA at those sites.8Studies that classify the type of facility where arrests are more likely to occur are valuable, although most arrests do not occur at the higher frequency sites. Improved methodologies are necessary to maximize the distribution and benefit of AED placement in the community. An alternative strategy is to identify the geographic location of each arrest and provide an AED for the areas with the higher frequency of OHCA. However, simply having an AED located near an arrest does not guarantee accessibility if, for example, the facility housing the AED is closed at the time of the arrest. Thus, AED coverage is dependent on both spatial and temporal accessibility. Highlighting the importance of restricted temporal access, a study of OHCAs in public locations in Copenhagen, Denmark, over a 7-year period demonstrated that 62% occurred during the evenings, nights, and weekends. Limited temporal accessibility resulted in a 53% coverage loss.10Sun and colleagues11 have previously reported a spatiotemporal analysis of registered AEDs in public locations in Toronto, Canada, identifying the location and time of day of all nontraumatic public OHCAs over an 8-year period. They found that the majority (61.0%) of all OHCAs occurred during the evening, night, and weekends, but of the locations housing the registered AEDs, 74% were not open 24 hours a day. Coverage loss, defined as the percentage of OHCAs that would not be covered because of limited hours of availability, was 32% during the evening, night, and weekends. Using a spatiotemporal model to optimize AED placement by taking into account both location and hours of operation, they predicted a 25% improvement in actual coverage. The greatest coverage gain was at night, when the existing AED network in Toronto experienced the greatest coverage loss, which also corresponds to the time period when survival rates were the lowest.In this issue of Circulation, Sun and colleagues12 build on previous studies to develop a potential strategy to maximize the impact of AED placement in Toronto. Using both spatial and temporal metrics, they evaluated the AED coverage if such devices were placed at businesses and municipal locations with ≥20 locations in Toronto (including convenience stores, automatic teller machines [ATMs], coffee shops, and restaurants). By using individual analyses for groupings of facilities or franchises (eg, Tim Hortons, Starbucks, or Royal Bank of Canada ATM), they determined the number of OHCAs that occurred within 100 meters of each location in terms of assumed coverage (assuming 24-hour availability of the AED) and actual coverage (AED available during the reported hours of operation). For obvious reasons, the actual coverage is a determinant of whether the nearby AED is available to treat the OHCA when needed.The modeling demonstrates that ATMs and coffee shops provided the greatest actual coverage, occupying 8 of the top 10 location types. These location categories also had high coverage efficiency, which is a measure of the actual coverage divided by the number of facilities, and indicates the potential impact obtained by placing a single AED at a specific location. As noted by the authors, locations such as ATMs and coffee shops have additional advantages for AED placement, including weather protection, additional security (ATMs have video surveillance), and increased accessibility (many ATMs have 24-hour access). Furthermore, providing public awareness that a specific coffee shop or bank brand has chosen to place AEDs in all their locations might increase the likelihood that a bystander would utilize a nearby AED at the moment of a cardiac arrest.Sun and colleagues12 are to be commended for important work that may inform policy for PAD programs. Their methodologies, applied to other cities, could result in city-specific recommendations. Rank lists of businesses with high actual coverage and coverage efficiency would assist PAD programs in developing public/commercial partnerships that maximize both impact and cost-effectiveness. We also commend the multidisciplinary methodology, which included expertise in emergency medicine and mechanical and industrial engineering; this sort of cross-disciplinary collaboration, using advanced analytical methods, is becoming increasingly important in healthcare research and quality improvement. Findings such as these could encourage collaboration between community PAD programs and recognizable business entities. Within these joint enterprises, businesses could collaborate in PAD efforts to achieve widespread distribution in franchise locations and increase public awareness.The authors' work leaves some unanswered questions. Survival from OHCA is not uniform among sites of occurrence, so the benefit from individual AEDs may vary. For example, in a study of Seattle and surrounding King County, Washington, survival with AED usage was higher at fitness facilities than at nonexercise indoor sites.13 As such, the likelihood of survival could be considered in future modeling. Whether systematic deployment of AEDs at high-ranking businesses will actually result in increased rates of bystander AED usage and subsequent OHCA survival needs to be tested in prospective studies. Furthermore, some findings may be specific to Toronto compared with other cities and communities (eg, the observed overall bystander CPR frequency of 46% and survival to discharge of 16% are lower than statistics found in some communities and higher than those of others).How might community PAD programs respond to the findings of Sun and colleagues?12 We see this as a call to action for communities and heart disease advocacy groups to explore public/commercial collaboration to enhance rational AED placement throughout areas of population density. This sort of partnership, providing substantial underwriting of AED costs, has been developed using electronic advertising in Korea14 and vending machine revenue in Japan.15 In such a partnership, the costs need not be assumed entirely by the community but rather shared by the business. For spatiotemporal AED distribution in public commercial sites, as suggested by Sun and colleagues, 12 the community might purchase the device and accept liability while the business provides funding for the AED purchase, maintenance, and marketing costs and, in return, receives the benefit of a charitable donation, publicity, and goodwill.OHCA remains a major public health problem that can be addressed by an AED that is both nearby and available to use. Future efforts should be committed to ensuring that an AED is in the right place at the right time.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Richard L. Page, MD, Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine & Public Health, Suite 5000, 1685 Highland Ave, Madison, WI 53705-2281. E-mail [email protected]References1. 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Recio Iglesias J, Díez-Manglano J, López García F, Díaz Peromingo J, Almagro P and Varela Aguilar J (2020) Management of the COPD Patient with Comorbidities: An Experts Recommendation Document, International Journal of Chronic Obstructive Pulmonary Disease, 10.2147/COPD.S242009, Volume 15, (1015-1037) March 21, 2017Vol 135, Issue 12 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.027305PMID: 28320804 Originally publishedMarch 21, 2017 Keywordscardiac arrestEditorialspublic access defibrillationautomated external defibrillatorPDF download Advertisement SubjectsArrhythmiasCardiopulmonary ArrestCardiopulmonary Resuscitation and Emergency Cardiac CareSudden Cardiac DeathVentricular Fibrillation
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