Elsevier

Australian Critical Care

Volume 20, Issue 4, November 2007, Pages 137-145
Australian Critical Care

Can lay responder defibrillation programmes improve survival to hospital discharge following an out-of-hospital cardiac arrest?

https://doi.org/10.1016/j.aucc.2007.08.003Get rights and content

Summary

Introduction

The importance of early defibrillation in improving outcomes and reducing morbidity following out-of-hospital cardiac arrest underscores the importance of examining novel approaches to treatment access. The increasing evidence to support the importance of early defibrillation has increased attention on the potential for lay responders to deliver this therapy.

Aim

This paper seeks to critically review the literature that evaluates the impact of lay responder defibrillator programs on survival to hospital discharge following an out-of-hospital cardiac arrest in the adult population.

Method

The electronic databases, Medline and CINAHL, were searched using keywords including; “first responder”, “lay responder”, “defibrillation” and “cardiac arrest”. The reference lists of retrieved articles and the Internet were also searched. Articles were included in the review if they reported primary data, in the English language, which described the effect of a lay responder defibrillation program on survival to hospital discharge from out-of-hospital cardiac arrest in adults.

Results

Eleven studies met the inclusion criteria. The small number of published studies, heterogeneity of study populations and study outcome methods prohibited formal meta-analysis. Therefore, narrative analysis was undertaken. Studies included in this report provided inconsistent findings in relation to survival to hospital discharge following out-of-hospital cardiac arrest.

Conclusion

Although there are limited data, the role of the lay responder appears promising in improving the outcome from out-of-hospital cardiac arrest following early defibrillation. Despite the inherent methodological difficulties in studying this population, future research should address outcomes related to morbidity, mortality and cost-effectiveness.

Introduction

Cardiovascular disease remains the leading cause of death in Australia1 where approximately 10,000 people die following out-of-hospital cardiac arrest each year.2 There are limited data about survival rates from unwitnessed out-of-hospital cardiac arrest in Australia with one report claiming survival rates to be less than 5%.3 This is not dissimilar to the international context.4, 5 Australians face unique challenges in relation to a large land mass with a sparse population distribution in many areas and limited access to emergency services, suggesting a system of response beyond traditional health services could be of value.

The four links in the chain of survival are described in Table 1.6 Of these four critical steps, early initiation of cardiopulmonary resuscitation (CPR) and defibrillation have both been identified as predictors of improved survival rates following out-of-hospital cardiac arrest.4, 7 Training of community members in CPR has occurred for many years. However, with the advent of new technology in the automated external defibrillator (AED), there is increasing interest in training non-medical persons to provide early defibrillation. Lay responders can use AEDs capably with regular training to maintain their skills.8, 9

Several models have been proposed to increase the availability of defibrillation within the community. Strategies to improve access include:

  • Responding non-medical emergency service personnel such as fire fighters and police officers equipped with automated external defibrillators, concurrent with ambulance dispatch10, 11, 12, 13, 14;

  • Locating automated defibrillators in public areas, such as airports and sports grounds, where they can be accessed by any member of the community14, 15, 16;

  • Home external defibrillators for those with a known high risk of cardiac arrest,17, 18 and;

  • Volunteer community first response groups equipped with automated external defibrillators, concurrent with ambulance dispatch.14, 15, 19, 20, 21, 22

This review specifically focuses on lay responder programs, rather than public access defibrillation programs. Lay responders are defined as a person other than a nurse, doctor or paramedic trained in advanced first aid and the use of an AED, who are part of an organized, medically controlled emergency response system.23 In contrast, the term public access defibrillation, refers to defibrillation using an AED by trained or untrained members of the community. These individuals are not part of a systematic model or approach to early response but rather opportunistically they provide defibrillation following a witnessed cardiac arrest.23 For example, from the studies reviewed, lay responders include police and fire officers, first aid personnel or lay staff (community) ambulance workers.

The lay responder role introduces issues relating to medico-legal concerns, professional gate keeping, currency of training and supervision. When changing traditional means of delivering health interventions, implementation and change management issues are the most challenging.24 Whilst the use of an AED by lay responders may achieve earlier access to defibrillation and be beneficial in improving outcomes from out-of-hospital cardiac arrest, data remains inconclusive. Improvements in mortality and functional outcomes will be key drivers in allocating resources to this type of initiative. Therefore, this paper seeks to review the literature related to lay responder defibrillation programs in terms of their effect on mortality and survival to hospital discharge in order to inform development of the role, particularly within the Australian context.

Section snippets

Method

The search strategy used to identify relevant papers in Medline (1966–2005) is described in Table 2. This strategy was adapted to the different subject headings used in CINAHL (1982–2005). Duplication of the search strategy using EMBASE did not generate additional data sources. The reference lists of retrieved papers were searched to identify additional papers. Additionally, the Internet was searched using the Google search engine for any unpublished data. Hand searching of recent journals and

Results

A total of 625 papers were identified using the search strategy described. Abstracts of these papers were reviewed by the primary author to assess whether the papers met the inclusion criteria. This process identified a significant number of papers that did not report an evaluation but rather were an editorial or descriptive article. Eleven studies met the inclusion criteria. These papers were then reviewed by co-authors to confirm that they met the inclusion criteria. Data were then extracted

Conclusion

The comparison of studies presented is challenging given the methodological heterogeneity of the data, comparisons across health care systems, time windows and the limitations of the integrated literature review method.

Best practice guidelines underscore the importance of early access to defibrillation and a range of interventions have been developed to facilitate this access.23, 44, 43 The review has identified that early defibrillation by targeted lay first responders may improve time to

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