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In New Zealand, there are close to 2,000 out-of-hospital cardiac arrests (OHCA) per year.1 Cardiac arrests fall into two categories; shockable rhythms (ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT)) and non-shockable rhythms (pulseless electrical activity (PEA), Asystole), which ultimately determine their management. For shockable rhythms, performing defibrillation as soon as VF/pVT are identified greatly increases the likelihood of achieving return of spontaneous circulation (ROSC) and thus survival.2,3

If VF is defibrillated within the first minute of collapse, the patient’s chances of survival are approximately 90%.1 For every minute that defibrillation is delayed, survival is reduced by 10–12%.4,5 If it is delayed by more than 10 minutes, the chance of survival is less than 5%.1 The median response time for emergency services called to a cardiac arrest call in New Zealand is six minutes in an urban community, and nine minutes in a rural/remote community.1 Therefore, if solely relying on an ambulance to provide a defibrillator, chances of survival will have dramatically decreased by the time paramedics have arrived. These statistics show how important early defibrillation is for shockable rhythms in OHCA cases, and therefore the importance of readily available AEDs in local communities.

In 2018, 74% of OHCA patients received cardiopulmonary resuscitation (CPR) by a bystander but only 5.1% were defibrillated by a public access automated external defibrillator (AED).1

The low number of public AED use in OHCA is not unique to New Zealand. This global problem has been recently reviewed by Delhomme et al, who listed the contributing factors to this issue under two categories; AED deployment issues (low public AED numbers, limited AED visibility and limited AED accessibility) and bystander-related issues (education and training in basic life support (BLS) manoeuvres and the willingness to initiate CPR).6

Improvements in all of these areas are hoped to increase the rate of public AED use in OHCA, and therefore survival. In this study, we focus on the AED accessibility and visibility in the city centre area of Hamilton, New Zealand. We test if these issues exist here and discuss what we can do to improve this.

Aims/objectives

There are a number of different ways of locating public AEDs—for example various apps which can be downloaded to a smart phone, and also community websites. At the time this study was carried out there were 50 AED locations listed on www.hamiltoncentral.co.nz in the Hamilton urban area, a website freely accessible to the public.

The aims of this study were to:

  1. Visit all 50 locations in person to assess their true availability
  2. Identify the precise AED location within these premises
  3. Review restrictions, if any, to device access
  4. Assess the visibility of the AED to the public as well as signposting for the device

Methods

A questionnaire was formed prior to visiting the AED locations, containing all pertinent questions to achieve the objectives above. All 50 sites listed were visited between 1 May 2018 and 22 August 2018.

The following questions were put to the first member of staff encountered to simulate an emergency. They were asked:

  1. If they were aware an AED was onsite
  2. Its precise location
  3. Hours of availability
  4. If restricted access applied (ie, key/PIN/staff member/swipe card access required to access AED)
  5. If the AED had ever been used.

Additionally, the visibility and signposting of the AED was assessed.

Results

AED location accuracy and AED use

Of the 50 locations listed, three sites no longer existed due to relocation or closure and two locations were duplicate listings. Therefore, only 45 AEDs existed out of 50.

The location of two AED sites grossly differed from the location described on the website. One of the AEDs was incorrectly listed as inside one of the retailers in a shopping centre, when in fact it was kept behind the information desk. As for the other inaccurate listing, the company had relocated to another part of the city taking its AED with it. Therefore, there was no AED at the location specified.

Four of the AEDs had been used or attempted to be used; two by the urgent care centre and the fire department. In the other two attempts, the pads were applied but it turned out not to be a cardiac arrest.

Additionally, two locations were identified that had AEDs on their premises but were not listed on the website. This was co-incidental while searching for AEDs listed on the webpage.

Staff awareness, education and accessibility

Of the first staff members encountered, 44 out of 45 knew that an AED was onsite and were able to identify the location of the AED without assistance. All but one of the 44 stated that they, or other staff members within the building, had received BLS and/or AED training.

For 33 out of 45 AEDs, a staff member was needed to help identify the location of the AED, 18 of which also supplied swipe card access which was needed to get to the device. Several AED locations were within office blocks with the office located above ground level. In these situations, access was only available via the lift as access to the stairs required a swipe card.

The majority of AEDs listed on the website were located at private companies, purchased with the primary intention of staff use. This was a common response when asked why they located their AED inside, or on a floor above ground level, rather than outside the premises. However, they also chose to list them on a public website as an accessible AED for the Hamilton community.

Figure 1: Graph illustrating the responses of the first staff members encountered at all 45 AED locations.

c


From left to right; (i) The number of staff aware that an AED was onsite (ii)The number of locations having at least one member of staff BLS trained (iii) The number of locations staff members are required to help locate device (iv) The number of locations a staff member is required for swipe card access to get to device.

Times of accessibility

In total, just three AEDs (7%) were available 24 hours a day, seven days a week. These were located at an urgent medical care centre, a fire station and a petrol station. Within the fire station, the AED was not located in the building itself, but on the fire trucks. The building is usually closed to the public and would require a phone call to the emergency services to alert the firefighters inside of the emergency.

In addition, there were three AEDs located within a college campus that are accessible to staff and students continuously, but not to the public. A student or staff swipe card would be required to enter the campus buildings outside of office hours as well as to open the locked case storing the device. For this reason, they were not deemed continuously available to the public.

Nine AEDs were accessible after 6pm on at least one day of the week. These include the six AEDs discussed above, it also includes one AED accessible for only one hour per week after 6pm. Thirteen AEDs were available on weekends; however, five of these would require swipe access to the building or to contact a member of staff to gain entry.

Figure 2: Graph illustrating the true availability of AEDs listed in Hamilton.

c

From left to right; (i) The actual number of AEDs in Hamilton (ii) Number of AEDs available continuously (iii) Number of AEDs available on the weekends (iv) Number of AEDs available after 6pm for at least one day of the week.

AED location, visibility and signposting

None of the 45 AEDs were located outside. Of the staff members surveyed, the most common reason quoted was due to fear of vandalism or theft. As many of these locations were in office blocks rented by the occupier, some of the staff surveyed felt they would not be able to securely encase their AED outside the building easily as that would require modifications approved by the landlord. Consequently, none of the AEDs were clearly visible to the public from the outside and only 10 were deemed visible from within the premises.

AED signage was also rare. Only eight premises had a sticker or sign on the outside identifying that an AED was located within the building. Typically, this was identified by placing a 20cm by 15cm sticker on the entrance doorway, a sign that would only be visible at close proximity. Six locations had signage within the building, while one had both.

Figure 3: Graph illustrating the number of AEDs located outside, those that are visible from outside and inside the premises and those with outdoor signposting accompanying the AED. This is out of a total of 45 AEDs.

c

Discussion

Far fewer than the original 50 listed AEDs are freely available to the public, particularly after 6pm or on weekends. There are errors on the website that could potentially waste time in a life-threatening situation. These include duplicate listings, sites that no longer exist and inaccurate descriptions of locations provided on the website. The website was contacted and the appropriate corrections have been made.

There are no outdoor AEDs available, with none of the AEDs listed clearly visible from the outside. Combined with the lack of signposting, there would be an inevitable delay in obtaining an AED in an OHCA. Access is further limited as many AEDs require assistance for location, swipe card access or both in order to obtain the defibrillator. Issues with accessibility were not unexpected as this has been identified as an issue in other studies. For example, a study was performed by Sun et al in 2016 investigating the AED accessibility issues in OHCA in Toronto, Canada. They found that between 2006 to 2014, one in five OHCAs occurred near an inaccessible AED at the time of the arrest, and that 61% of all OHCAs occurred during the evening, night and weekends.7 Similar findings would be expected to found if the same study was performed here in Hamilton given the results of our research.

There are likely more AEDs within the community that could be listed online, as evidenced by the coincidental finding of two AEDs. Only one of the AEDs listed is located within a sports complex. More AEDs could be identified by reaching out to sports clubs and training facilities within Hamilton informing them of the website.

We would recommend the following in order to improve the issues with accessibility and visibility:

1. Increase the number of outdoor AEDs

There needs to be more publicly available AEDs located in more visible outdoor locations. One possible solution would be to convert old/unused telephone booths into secure AED locations as seen in Ireland.8 Telephone booths are becoming increasingly obsolete and are usually located in focal points within a town or city. Therefore, converting old telephone booths to an AED location would provide a highly visible and secure defibrillator to the public (Figure 4).9

Figure 4: Telephone booth converted to contain an AED in Killarney, Ireland.

c

Image used with permission by Heart of Killarney, http://heartofkillarney.ie/fossa/

To ease the public concern of vandalism and theft, outdoor AEDs can be housed in secure casings that require a pin code from emergency services. An example of such is provided in Figure 5 below, seen on Waiheke Island, New Zealand.

Figure 5: Example of secure outdoor AED casing on Waiheke Island, New Zealand.

c

Photo taken by author.

2. Increase signposting of AED locations

We recommend that all premises should highlight that an AED is within the building. Ideally with a sticker or sign that is larger than the current ones provided as they are only visible at close range.

3. Use of smartphone applications to locate AEDs

Even though the Hamilton Central website is useful in locating AEDs, it is not the website’s primary function. There are smartphone applications dedicated solely to listing AED locations as well as alerting trained bystanders to help in an OHCA. These apps also have a larger number of devices listed compared to the website.

The GoodSAM smartphone app was introduced to New Zealand in 2018, originally designed in London.10 The app alerts the three closest registered users to an OHCA at the same time the ambulance services are alerted. Registered users can also alert bystanders using the ‘Alerter’ function. All users of the app must prove that they are BLS trained before registering. Responders have 20 seconds to accept the alert, otherwise it moves onto the next nearest bystander. The responder that is closest to a listed AED is directed to collect the device and bring it to the arrest.10 The aim of the app is to improve the morbidity and mortality of OHCA sufferers by decreasing the time to first shock as well as time to commencing CPR.

There is no scientific evidence yet that this particular app is proven to be beneficial; however, similar alerting systems have shown to improve survival rates. A text message-based alert system in the Netherlands showed that OHCA victims were 2.8 times more likely to survive if their arrest was attended by an alerted rescuer versus those that were not.11 Hopefully, similar findings will support the GoodSAM application when audited.

Another application is available in New Zealand that solely lists the locations of all nearby AED devices. ‘AED Locations’ is an app created by Gareth Jenkin, a resuscitation coordinator at Auckland City Hospital, which has over 9,000 AED locations listed.12 In this app, the option is also available to include the hours each AED is accessible, which could avoid wasting time in attempting to obtain a defibrillator.

4. Regular audits of AED applications and websites

As applications and websites expand, and AED lists become longer, the potential for inaccuracies grows as it becomes more difficult to regularly audit. In our study alone, there were errors in seven out of the original 50 listed (duplicate listings, no longer exist or inaccurate locations), 14% of our relatively small sample size. The responsibility has to be shared with those who list their device to maintain the accuracy of its location and accessible times, especially as these applications continue to grow.

5. Only show the available AEDs at the time the list is accessed

With all AED listing websites and applications, we strongly recommend that the times that the device is available should be added to the information accompanying the device. If possible, the lists should only show the AEDs that are truly available at the time the list is accessed.

6. Use of alternative AED sources and technologies

Alternatives to fixed location public AEDs have been investigated with the potential for success. The use of drones to deliver AEDs has the potential to reduce the time of first shock in OHCA. In Sweden, they recreated previous OHCA events and used drones to deliver an AED to those exact locations. They then compared the dispatch to arrival time of the paramedics that had arrived versus the drone. The median time from dispatch to arrival of the paramedics was 22:00 minutes vs 5:21 for the drone (P<.001). The drone was also quicker in all cases with a median reduction in response time of 16:39 minutes (P<.001).13 Even though this study showed large reductions in defibrillator arrival times, there would be multiple difficulties in implementing a system like this, including cost, training, weather and airspace restrictions to name a few.13

Other technologies that may be beneficial include battery-operated pocket defibrillators carried by members of appropriate services such as police officers.14 More research is needed to see if these are beneficial and practical in real life scenarios.

Limitations

In retrospect, there are additional questions that could have been asked during the study that would have been of value. The accurate number of AEDs that required lift access would have been of interest as it was a noticeable obstacle in some cases. An opportunity was missed to question if all AEDs were operational and up to date with servicing. Previous knowledge of the website could have been assessed by surveying the staff members encountered. All would be valuable information in a re-audit in the future or a similar study in another city.

Conclusion

During office hours there is a reasonable number of accessible AEDs in Hamilton. Access to public AEDs is limited outside office hours, with only 7% of AEDs available 24 hours, seven days a week. This is mainly due to restrictions to access. Simple measures could increase availability and public awareness of this life-saving equipment.

Summary

Abstract

Last year, there were 2,000 out-of-hospital cardiac arrests (OHCA) in New Zealand, 74% received CPR but only 5.1% accessed an automated external defibrillator (AED). The average survival rate of OHCA is 13%. The aim of this study was to visit all 50 AED locations shown on www.hamiltoncentral.co.nz to assess their true availability and visibility to the public in the event of an OHCA.

Aim

Method

All premises were visited and the first staff member encountered was asked if they were aware an AED was onsite, its location, hours of availability, if restricted access applied and whether it had been used.

Results

Of the 50 locations, three sites no longer exist and two AEDs were listed twice. Therefore, only 45 AEDs exist. Two sites had grossly inaccurate locations. Three AEDs (7%) were continuously available. Nine AEDs were accessible after 6pm at least one day of the week. Thirteen AEDs were available on weekends; however, five required swipe card access. None of the AEDs were located outdoors.

Conclusion

ar fewer than 50 listed AEDs are freely available to the public, especially after 6pm and on weekends. Lack of signposting and restrictions to access would lead to delayed defibrillation. This important health issue needs addressing.

Author Information

Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton;-Janice Swampillai, Electrophysiologist, Waikato DHB and Senior Lecturer Waikato Clinical School, University of Auckland, Auckland; Martin K Stiles, Director of Cardiac Electrophysiology, Waikato Hospital and Waikato Clinical School, University of Auckland, Auckland.

Acknowledgements

We would like to acknowledge Dr Tammy Pegg, Nelson Marlborough Hospital, for her help with the concept of the audit.

Correspondence

Dr Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton.

Correspondence Email

peter.o'callaghan@waikatodhb.health.nz

Competing Interests

Nil.

  1. Dicker B, Oliver V, Tunnage B. (2018) Out-of-Hospital Cardiac Arrest Registry Annual Report 2017/2018, New Zealand: The St John New Zealand Registry Group.
  2. Capucci A, Aschieri D, Piepoli MF, et al. Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation. Circulation. 2002 Aug 27; 106(9):1065–70.
  3. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015; 372:2307–15.
  4. Jost D, Degrange H, Verret C, et al. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010; 121:1614–22.
  5. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015; 95:81–99.
  6. Delhomme C, Njeim M, Varlet E, et al. Automated external defibrillator use in out-of-hospital cardiac arrest: Current limitations and solutions. Arch Cardiovasc Dis. 2019 Mar; 112(3):217–222.
  7. Sun CL, Demirtas D, Brooks SC, et al. Overcoming Spatial and Temporal Barriers to Public Access Defibrillators Via Optimization. J Am Coll Cardiol. 2016 Aug 23; 68(8):836–45.
  8. Clifford G. (2016) ‘How phone boxes are saving lives - and where to find them’, Irish Independent. 10th November, online article. (accessed 07 May 2019).
  9. Image: Maven Services. Heart of Killarney. http://heartofkillarney.ie/fossa/ (accessed 07 May 2019).
  10. Smith CM, Wilson MH, Ghorbangholi A, et al. The use of trained volunteers in the response to out-of-hospital cardiac arrest - the GoodSAM experience. Resuscitation. 2017 Dec; 121:123–126.
  11. Pijls RW, Nelemans PJ, Rahel BM, et al. A text message alert system for trained volunteers improves out-of-hospital cardiac arrest survival. Resuscitation. 2016 Aug; 105:182–7.
  12. AED Locations. AED Locations. http://aedlocations.co.nz/about/ (accessed 07 May 2019).
  13. Claesson A, Bäckman A, Ringh M, et al. Time to Delivery of an Automated External Defibrillator Using a Drone for Simulated Out-of-Hospital Cardiac Arrests vs Emergency Medical Services. JAMA. 2017 Jun 13; 317(22):2332–2334.
  14. Radcliffe Cardiology. FRED Easyport. http://www.radcliffecardiology.com/products/fred-easyport (accessed 05 May 2019).

For the PDF of this article,
contact nzmj@nzma.org.nz

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In New Zealand, there are close to 2,000 out-of-hospital cardiac arrests (OHCA) per year.1 Cardiac arrests fall into two categories; shockable rhythms (ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT)) and non-shockable rhythms (pulseless electrical activity (PEA), Asystole), which ultimately determine their management. For shockable rhythms, performing defibrillation as soon as VF/pVT are identified greatly increases the likelihood of achieving return of spontaneous circulation (ROSC) and thus survival.2,3

If VF is defibrillated within the first minute of collapse, the patient’s chances of survival are approximately 90%.1 For every minute that defibrillation is delayed, survival is reduced by 10–12%.4,5 If it is delayed by more than 10 minutes, the chance of survival is less than 5%.1 The median response time for emergency services called to a cardiac arrest call in New Zealand is six minutes in an urban community, and nine minutes in a rural/remote community.1 Therefore, if solely relying on an ambulance to provide a defibrillator, chances of survival will have dramatically decreased by the time paramedics have arrived. These statistics show how important early defibrillation is for shockable rhythms in OHCA cases, and therefore the importance of readily available AEDs in local communities.

In 2018, 74% of OHCA patients received cardiopulmonary resuscitation (CPR) by a bystander but only 5.1% were defibrillated by a public access automated external defibrillator (AED).1

The low number of public AED use in OHCA is not unique to New Zealand. This global problem has been recently reviewed by Delhomme et al, who listed the contributing factors to this issue under two categories; AED deployment issues (low public AED numbers, limited AED visibility and limited AED accessibility) and bystander-related issues (education and training in basic life support (BLS) manoeuvres and the willingness to initiate CPR).6

Improvements in all of these areas are hoped to increase the rate of public AED use in OHCA, and therefore survival. In this study, we focus on the AED accessibility and visibility in the city centre area of Hamilton, New Zealand. We test if these issues exist here and discuss what we can do to improve this.

Aims/objectives

There are a number of different ways of locating public AEDs—for example various apps which can be downloaded to a smart phone, and also community websites. At the time this study was carried out there were 50 AED locations listed on www.hamiltoncentral.co.nz in the Hamilton urban area, a website freely accessible to the public.

The aims of this study were to:

  1. Visit all 50 locations in person to assess their true availability
  2. Identify the precise AED location within these premises
  3. Review restrictions, if any, to device access
  4. Assess the visibility of the AED to the public as well as signposting for the device

Methods

A questionnaire was formed prior to visiting the AED locations, containing all pertinent questions to achieve the objectives above. All 50 sites listed were visited between 1 May 2018 and 22 August 2018.

The following questions were put to the first member of staff encountered to simulate an emergency. They were asked:

  1. If they were aware an AED was onsite
  2. Its precise location
  3. Hours of availability
  4. If restricted access applied (ie, key/PIN/staff member/swipe card access required to access AED)
  5. If the AED had ever been used.

Additionally, the visibility and signposting of the AED was assessed.

Results

AED location accuracy and AED use

Of the 50 locations listed, three sites no longer existed due to relocation or closure and two locations were duplicate listings. Therefore, only 45 AEDs existed out of 50.

The location of two AED sites grossly differed from the location described on the website. One of the AEDs was incorrectly listed as inside one of the retailers in a shopping centre, when in fact it was kept behind the information desk. As for the other inaccurate listing, the company had relocated to another part of the city taking its AED with it. Therefore, there was no AED at the location specified.

Four of the AEDs had been used or attempted to be used; two by the urgent care centre and the fire department. In the other two attempts, the pads were applied but it turned out not to be a cardiac arrest.

Additionally, two locations were identified that had AEDs on their premises but were not listed on the website. This was co-incidental while searching for AEDs listed on the webpage.

Staff awareness, education and accessibility

Of the first staff members encountered, 44 out of 45 knew that an AED was onsite and were able to identify the location of the AED without assistance. All but one of the 44 stated that they, or other staff members within the building, had received BLS and/or AED training.

For 33 out of 45 AEDs, a staff member was needed to help identify the location of the AED, 18 of which also supplied swipe card access which was needed to get to the device. Several AED locations were within office blocks with the office located above ground level. In these situations, access was only available via the lift as access to the stairs required a swipe card.

The majority of AEDs listed on the website were located at private companies, purchased with the primary intention of staff use. This was a common response when asked why they located their AED inside, or on a floor above ground level, rather than outside the premises. However, they also chose to list them on a public website as an accessible AED for the Hamilton community.

Figure 1: Graph illustrating the responses of the first staff members encountered at all 45 AED locations.

c


From left to right; (i) The number of staff aware that an AED was onsite (ii)The number of locations having at least one member of staff BLS trained (iii) The number of locations staff members are required to help locate device (iv) The number of locations a staff member is required for swipe card access to get to device.

Times of accessibility

In total, just three AEDs (7%) were available 24 hours a day, seven days a week. These were located at an urgent medical care centre, a fire station and a petrol station. Within the fire station, the AED was not located in the building itself, but on the fire trucks. The building is usually closed to the public and would require a phone call to the emergency services to alert the firefighters inside of the emergency.

In addition, there were three AEDs located within a college campus that are accessible to staff and students continuously, but not to the public. A student or staff swipe card would be required to enter the campus buildings outside of office hours as well as to open the locked case storing the device. For this reason, they were not deemed continuously available to the public.

Nine AEDs were accessible after 6pm on at least one day of the week. These include the six AEDs discussed above, it also includes one AED accessible for only one hour per week after 6pm. Thirteen AEDs were available on weekends; however, five of these would require swipe access to the building or to contact a member of staff to gain entry.

Figure 2: Graph illustrating the true availability of AEDs listed in Hamilton.

c

From left to right; (i) The actual number of AEDs in Hamilton (ii) Number of AEDs available continuously (iii) Number of AEDs available on the weekends (iv) Number of AEDs available after 6pm for at least one day of the week.

AED location, visibility and signposting

None of the 45 AEDs were located outside. Of the staff members surveyed, the most common reason quoted was due to fear of vandalism or theft. As many of these locations were in office blocks rented by the occupier, some of the staff surveyed felt they would not be able to securely encase their AED outside the building easily as that would require modifications approved by the landlord. Consequently, none of the AEDs were clearly visible to the public from the outside and only 10 were deemed visible from within the premises.

AED signage was also rare. Only eight premises had a sticker or sign on the outside identifying that an AED was located within the building. Typically, this was identified by placing a 20cm by 15cm sticker on the entrance doorway, a sign that would only be visible at close proximity. Six locations had signage within the building, while one had both.

Figure 3: Graph illustrating the number of AEDs located outside, those that are visible from outside and inside the premises and those with outdoor signposting accompanying the AED. This is out of a total of 45 AEDs.

c

Discussion

Far fewer than the original 50 listed AEDs are freely available to the public, particularly after 6pm or on weekends. There are errors on the website that could potentially waste time in a life-threatening situation. These include duplicate listings, sites that no longer exist and inaccurate descriptions of locations provided on the website. The website was contacted and the appropriate corrections have been made.

There are no outdoor AEDs available, with none of the AEDs listed clearly visible from the outside. Combined with the lack of signposting, there would be an inevitable delay in obtaining an AED in an OHCA. Access is further limited as many AEDs require assistance for location, swipe card access or both in order to obtain the defibrillator. Issues with accessibility were not unexpected as this has been identified as an issue in other studies. For example, a study was performed by Sun et al in 2016 investigating the AED accessibility issues in OHCA in Toronto, Canada. They found that between 2006 to 2014, one in five OHCAs occurred near an inaccessible AED at the time of the arrest, and that 61% of all OHCAs occurred during the evening, night and weekends.7 Similar findings would be expected to found if the same study was performed here in Hamilton given the results of our research.

There are likely more AEDs within the community that could be listed online, as evidenced by the coincidental finding of two AEDs. Only one of the AEDs listed is located within a sports complex. More AEDs could be identified by reaching out to sports clubs and training facilities within Hamilton informing them of the website.

We would recommend the following in order to improve the issues with accessibility and visibility:

1. Increase the number of outdoor AEDs

There needs to be more publicly available AEDs located in more visible outdoor locations. One possible solution would be to convert old/unused telephone booths into secure AED locations as seen in Ireland.8 Telephone booths are becoming increasingly obsolete and are usually located in focal points within a town or city. Therefore, converting old telephone booths to an AED location would provide a highly visible and secure defibrillator to the public (Figure 4).9

Figure 4: Telephone booth converted to contain an AED in Killarney, Ireland.

c

Image used with permission by Heart of Killarney, http://heartofkillarney.ie/fossa/

To ease the public concern of vandalism and theft, outdoor AEDs can be housed in secure casings that require a pin code from emergency services. An example of such is provided in Figure 5 below, seen on Waiheke Island, New Zealand.

Figure 5: Example of secure outdoor AED casing on Waiheke Island, New Zealand.

c

Photo taken by author.

2. Increase signposting of AED locations

We recommend that all premises should highlight that an AED is within the building. Ideally with a sticker or sign that is larger than the current ones provided as they are only visible at close range.

3. Use of smartphone applications to locate AEDs

Even though the Hamilton Central website is useful in locating AEDs, it is not the website’s primary function. There are smartphone applications dedicated solely to listing AED locations as well as alerting trained bystanders to help in an OHCA. These apps also have a larger number of devices listed compared to the website.

The GoodSAM smartphone app was introduced to New Zealand in 2018, originally designed in London.10 The app alerts the three closest registered users to an OHCA at the same time the ambulance services are alerted. Registered users can also alert bystanders using the ‘Alerter’ function. All users of the app must prove that they are BLS trained before registering. Responders have 20 seconds to accept the alert, otherwise it moves onto the next nearest bystander. The responder that is closest to a listed AED is directed to collect the device and bring it to the arrest.10 The aim of the app is to improve the morbidity and mortality of OHCA sufferers by decreasing the time to first shock as well as time to commencing CPR.

There is no scientific evidence yet that this particular app is proven to be beneficial; however, similar alerting systems have shown to improve survival rates. A text message-based alert system in the Netherlands showed that OHCA victims were 2.8 times more likely to survive if their arrest was attended by an alerted rescuer versus those that were not.11 Hopefully, similar findings will support the GoodSAM application when audited.

Another application is available in New Zealand that solely lists the locations of all nearby AED devices. ‘AED Locations’ is an app created by Gareth Jenkin, a resuscitation coordinator at Auckland City Hospital, which has over 9,000 AED locations listed.12 In this app, the option is also available to include the hours each AED is accessible, which could avoid wasting time in attempting to obtain a defibrillator.

4. Regular audits of AED applications and websites

As applications and websites expand, and AED lists become longer, the potential for inaccuracies grows as it becomes more difficult to regularly audit. In our study alone, there were errors in seven out of the original 50 listed (duplicate listings, no longer exist or inaccurate locations), 14% of our relatively small sample size. The responsibility has to be shared with those who list their device to maintain the accuracy of its location and accessible times, especially as these applications continue to grow.

5. Only show the available AEDs at the time the list is accessed

With all AED listing websites and applications, we strongly recommend that the times that the device is available should be added to the information accompanying the device. If possible, the lists should only show the AEDs that are truly available at the time the list is accessed.

6. Use of alternative AED sources and technologies

Alternatives to fixed location public AEDs have been investigated with the potential for success. The use of drones to deliver AEDs has the potential to reduce the time of first shock in OHCA. In Sweden, they recreated previous OHCA events and used drones to deliver an AED to those exact locations. They then compared the dispatch to arrival time of the paramedics that had arrived versus the drone. The median time from dispatch to arrival of the paramedics was 22:00 minutes vs 5:21 for the drone (P<.001). The drone was also quicker in all cases with a median reduction in response time of 16:39 minutes (P<.001).13 Even though this study showed large reductions in defibrillator arrival times, there would be multiple difficulties in implementing a system like this, including cost, training, weather and airspace restrictions to name a few.13

Other technologies that may be beneficial include battery-operated pocket defibrillators carried by members of appropriate services such as police officers.14 More research is needed to see if these are beneficial and practical in real life scenarios.

Limitations

In retrospect, there are additional questions that could have been asked during the study that would have been of value. The accurate number of AEDs that required lift access would have been of interest as it was a noticeable obstacle in some cases. An opportunity was missed to question if all AEDs were operational and up to date with servicing. Previous knowledge of the website could have been assessed by surveying the staff members encountered. All would be valuable information in a re-audit in the future or a similar study in another city.

Conclusion

During office hours there is a reasonable number of accessible AEDs in Hamilton. Access to public AEDs is limited outside office hours, with only 7% of AEDs available 24 hours, seven days a week. This is mainly due to restrictions to access. Simple measures could increase availability and public awareness of this life-saving equipment.

Summary

Abstract

Last year, there were 2,000 out-of-hospital cardiac arrests (OHCA) in New Zealand, 74% received CPR but only 5.1% accessed an automated external defibrillator (AED). The average survival rate of OHCA is 13%. The aim of this study was to visit all 50 AED locations shown on www.hamiltoncentral.co.nz to assess their true availability and visibility to the public in the event of an OHCA.

Aim

Method

All premises were visited and the first staff member encountered was asked if they were aware an AED was onsite, its location, hours of availability, if restricted access applied and whether it had been used.

Results

Of the 50 locations, three sites no longer exist and two AEDs were listed twice. Therefore, only 45 AEDs exist. Two sites had grossly inaccurate locations. Three AEDs (7%) were continuously available. Nine AEDs were accessible after 6pm at least one day of the week. Thirteen AEDs were available on weekends; however, five required swipe card access. None of the AEDs were located outdoors.

Conclusion

ar fewer than 50 listed AEDs are freely available to the public, especially after 6pm and on weekends. Lack of signposting and restrictions to access would lead to delayed defibrillation. This important health issue needs addressing.

Author Information

Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton;-Janice Swampillai, Electrophysiologist, Waikato DHB and Senior Lecturer Waikato Clinical School, University of Auckland, Auckland; Martin K Stiles, Director of Cardiac Electrophysiology, Waikato Hospital and Waikato Clinical School, University of Auckland, Auckland.

Acknowledgements

We would like to acknowledge Dr Tammy Pegg, Nelson Marlborough Hospital, for her help with the concept of the audit.

Correspondence

Dr Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton.

Correspondence Email

peter.o'callaghan@waikatodhb.health.nz

Competing Interests

Nil.

  1. Dicker B, Oliver V, Tunnage B. (2018) Out-of-Hospital Cardiac Arrest Registry Annual Report 2017/2018, New Zealand: The St John New Zealand Registry Group.
  2. Capucci A, Aschieri D, Piepoli MF, et al. Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation. Circulation. 2002 Aug 27; 106(9):1065–70.
  3. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015; 372:2307–15.
  4. Jost D, Degrange H, Verret C, et al. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010; 121:1614–22.
  5. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015; 95:81–99.
  6. Delhomme C, Njeim M, Varlet E, et al. Automated external defibrillator use in out-of-hospital cardiac arrest: Current limitations and solutions. Arch Cardiovasc Dis. 2019 Mar; 112(3):217–222.
  7. Sun CL, Demirtas D, Brooks SC, et al. Overcoming Spatial and Temporal Barriers to Public Access Defibrillators Via Optimization. J Am Coll Cardiol. 2016 Aug 23; 68(8):836–45.
  8. Clifford G. (2016) ‘How phone boxes are saving lives - and where to find them’, Irish Independent. 10th November, online article. (accessed 07 May 2019).
  9. Image: Maven Services. Heart of Killarney. http://heartofkillarney.ie/fossa/ (accessed 07 May 2019).
  10. Smith CM, Wilson MH, Ghorbangholi A, et al. The use of trained volunteers in the response to out-of-hospital cardiac arrest - the GoodSAM experience. Resuscitation. 2017 Dec; 121:123–126.
  11. Pijls RW, Nelemans PJ, Rahel BM, et al. A text message alert system for trained volunteers improves out-of-hospital cardiac arrest survival. Resuscitation. 2016 Aug; 105:182–7.
  12. AED Locations. AED Locations. http://aedlocations.co.nz/about/ (accessed 07 May 2019).
  13. Claesson A, Bäckman A, Ringh M, et al. Time to Delivery of an Automated External Defibrillator Using a Drone for Simulated Out-of-Hospital Cardiac Arrests vs Emergency Medical Services. JAMA. 2017 Jun 13; 317(22):2332–2334.
  14. Radcliffe Cardiology. FRED Easyport. http://www.radcliffecardiology.com/products/fred-easyport (accessed 05 May 2019).

For the PDF of this article,
contact nzmj@nzma.org.nz

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In New Zealand, there are close to 2,000 out-of-hospital cardiac arrests (OHCA) per year.1 Cardiac arrests fall into two categories; shockable rhythms (ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT)) and non-shockable rhythms (pulseless electrical activity (PEA), Asystole), which ultimately determine their management. For shockable rhythms, performing defibrillation as soon as VF/pVT are identified greatly increases the likelihood of achieving return of spontaneous circulation (ROSC) and thus survival.2,3

If VF is defibrillated within the first minute of collapse, the patient’s chances of survival are approximately 90%.1 For every minute that defibrillation is delayed, survival is reduced by 10–12%.4,5 If it is delayed by more than 10 minutes, the chance of survival is less than 5%.1 The median response time for emergency services called to a cardiac arrest call in New Zealand is six minutes in an urban community, and nine minutes in a rural/remote community.1 Therefore, if solely relying on an ambulance to provide a defibrillator, chances of survival will have dramatically decreased by the time paramedics have arrived. These statistics show how important early defibrillation is for shockable rhythms in OHCA cases, and therefore the importance of readily available AEDs in local communities.

In 2018, 74% of OHCA patients received cardiopulmonary resuscitation (CPR) by a bystander but only 5.1% were defibrillated by a public access automated external defibrillator (AED).1

The low number of public AED use in OHCA is not unique to New Zealand. This global problem has been recently reviewed by Delhomme et al, who listed the contributing factors to this issue under two categories; AED deployment issues (low public AED numbers, limited AED visibility and limited AED accessibility) and bystander-related issues (education and training in basic life support (BLS) manoeuvres and the willingness to initiate CPR).6

Improvements in all of these areas are hoped to increase the rate of public AED use in OHCA, and therefore survival. In this study, we focus on the AED accessibility and visibility in the city centre area of Hamilton, New Zealand. We test if these issues exist here and discuss what we can do to improve this.

Aims/objectives

There are a number of different ways of locating public AEDs—for example various apps which can be downloaded to a smart phone, and also community websites. At the time this study was carried out there were 50 AED locations listed on www.hamiltoncentral.co.nz in the Hamilton urban area, a website freely accessible to the public.

The aims of this study were to:

  1. Visit all 50 locations in person to assess their true availability
  2. Identify the precise AED location within these premises
  3. Review restrictions, if any, to device access
  4. Assess the visibility of the AED to the public as well as signposting for the device

Methods

A questionnaire was formed prior to visiting the AED locations, containing all pertinent questions to achieve the objectives above. All 50 sites listed were visited between 1 May 2018 and 22 August 2018.

The following questions were put to the first member of staff encountered to simulate an emergency. They were asked:

  1. If they were aware an AED was onsite
  2. Its precise location
  3. Hours of availability
  4. If restricted access applied (ie, key/PIN/staff member/swipe card access required to access AED)
  5. If the AED had ever been used.

Additionally, the visibility and signposting of the AED was assessed.

Results

AED location accuracy and AED use

Of the 50 locations listed, three sites no longer existed due to relocation or closure and two locations were duplicate listings. Therefore, only 45 AEDs existed out of 50.

The location of two AED sites grossly differed from the location described on the website. One of the AEDs was incorrectly listed as inside one of the retailers in a shopping centre, when in fact it was kept behind the information desk. As for the other inaccurate listing, the company had relocated to another part of the city taking its AED with it. Therefore, there was no AED at the location specified.

Four of the AEDs had been used or attempted to be used; two by the urgent care centre and the fire department. In the other two attempts, the pads were applied but it turned out not to be a cardiac arrest.

Additionally, two locations were identified that had AEDs on their premises but were not listed on the website. This was co-incidental while searching for AEDs listed on the webpage.

Staff awareness, education and accessibility

Of the first staff members encountered, 44 out of 45 knew that an AED was onsite and were able to identify the location of the AED without assistance. All but one of the 44 stated that they, or other staff members within the building, had received BLS and/or AED training.

For 33 out of 45 AEDs, a staff member was needed to help identify the location of the AED, 18 of which also supplied swipe card access which was needed to get to the device. Several AED locations were within office blocks with the office located above ground level. In these situations, access was only available via the lift as access to the stairs required a swipe card.

The majority of AEDs listed on the website were located at private companies, purchased with the primary intention of staff use. This was a common response when asked why they located their AED inside, or on a floor above ground level, rather than outside the premises. However, they also chose to list them on a public website as an accessible AED for the Hamilton community.

Figure 1: Graph illustrating the responses of the first staff members encountered at all 45 AED locations.

c


From left to right; (i) The number of staff aware that an AED was onsite (ii)The number of locations having at least one member of staff BLS trained (iii) The number of locations staff members are required to help locate device (iv) The number of locations a staff member is required for swipe card access to get to device.

Times of accessibility

In total, just three AEDs (7%) were available 24 hours a day, seven days a week. These were located at an urgent medical care centre, a fire station and a petrol station. Within the fire station, the AED was not located in the building itself, but on the fire trucks. The building is usually closed to the public and would require a phone call to the emergency services to alert the firefighters inside of the emergency.

In addition, there were three AEDs located within a college campus that are accessible to staff and students continuously, but not to the public. A student or staff swipe card would be required to enter the campus buildings outside of office hours as well as to open the locked case storing the device. For this reason, they were not deemed continuously available to the public.

Nine AEDs were accessible after 6pm on at least one day of the week. These include the six AEDs discussed above, it also includes one AED accessible for only one hour per week after 6pm. Thirteen AEDs were available on weekends; however, five of these would require swipe access to the building or to contact a member of staff to gain entry.

Figure 2: Graph illustrating the true availability of AEDs listed in Hamilton.

c

From left to right; (i) The actual number of AEDs in Hamilton (ii) Number of AEDs available continuously (iii) Number of AEDs available on the weekends (iv) Number of AEDs available after 6pm for at least one day of the week.

AED location, visibility and signposting

None of the 45 AEDs were located outside. Of the staff members surveyed, the most common reason quoted was due to fear of vandalism or theft. As many of these locations were in office blocks rented by the occupier, some of the staff surveyed felt they would not be able to securely encase their AED outside the building easily as that would require modifications approved by the landlord. Consequently, none of the AEDs were clearly visible to the public from the outside and only 10 were deemed visible from within the premises.

AED signage was also rare. Only eight premises had a sticker or sign on the outside identifying that an AED was located within the building. Typically, this was identified by placing a 20cm by 15cm sticker on the entrance doorway, a sign that would only be visible at close proximity. Six locations had signage within the building, while one had both.

Figure 3: Graph illustrating the number of AEDs located outside, those that are visible from outside and inside the premises and those with outdoor signposting accompanying the AED. This is out of a total of 45 AEDs.

c

Discussion

Far fewer than the original 50 listed AEDs are freely available to the public, particularly after 6pm or on weekends. There are errors on the website that could potentially waste time in a life-threatening situation. These include duplicate listings, sites that no longer exist and inaccurate descriptions of locations provided on the website. The website was contacted and the appropriate corrections have been made.

There are no outdoor AEDs available, with none of the AEDs listed clearly visible from the outside. Combined with the lack of signposting, there would be an inevitable delay in obtaining an AED in an OHCA. Access is further limited as many AEDs require assistance for location, swipe card access or both in order to obtain the defibrillator. Issues with accessibility were not unexpected as this has been identified as an issue in other studies. For example, a study was performed by Sun et al in 2016 investigating the AED accessibility issues in OHCA in Toronto, Canada. They found that between 2006 to 2014, one in five OHCAs occurred near an inaccessible AED at the time of the arrest, and that 61% of all OHCAs occurred during the evening, night and weekends.7 Similar findings would be expected to found if the same study was performed here in Hamilton given the results of our research.

There are likely more AEDs within the community that could be listed online, as evidenced by the coincidental finding of two AEDs. Only one of the AEDs listed is located within a sports complex. More AEDs could be identified by reaching out to sports clubs and training facilities within Hamilton informing them of the website.

We would recommend the following in order to improve the issues with accessibility and visibility:

1. Increase the number of outdoor AEDs

There needs to be more publicly available AEDs located in more visible outdoor locations. One possible solution would be to convert old/unused telephone booths into secure AED locations as seen in Ireland.8 Telephone booths are becoming increasingly obsolete and are usually located in focal points within a town or city. Therefore, converting old telephone booths to an AED location would provide a highly visible and secure defibrillator to the public (Figure 4).9

Figure 4: Telephone booth converted to contain an AED in Killarney, Ireland.

c

Image used with permission by Heart of Killarney, http://heartofkillarney.ie/fossa/

To ease the public concern of vandalism and theft, outdoor AEDs can be housed in secure casings that require a pin code from emergency services. An example of such is provided in Figure 5 below, seen on Waiheke Island, New Zealand.

Figure 5: Example of secure outdoor AED casing on Waiheke Island, New Zealand.

c

Photo taken by author.

2. Increase signposting of AED locations

We recommend that all premises should highlight that an AED is within the building. Ideally with a sticker or sign that is larger than the current ones provided as they are only visible at close range.

3. Use of smartphone applications to locate AEDs

Even though the Hamilton Central website is useful in locating AEDs, it is not the website’s primary function. There are smartphone applications dedicated solely to listing AED locations as well as alerting trained bystanders to help in an OHCA. These apps also have a larger number of devices listed compared to the website.

The GoodSAM smartphone app was introduced to New Zealand in 2018, originally designed in London.10 The app alerts the three closest registered users to an OHCA at the same time the ambulance services are alerted. Registered users can also alert bystanders using the ‘Alerter’ function. All users of the app must prove that they are BLS trained before registering. Responders have 20 seconds to accept the alert, otherwise it moves onto the next nearest bystander. The responder that is closest to a listed AED is directed to collect the device and bring it to the arrest.10 The aim of the app is to improve the morbidity and mortality of OHCA sufferers by decreasing the time to first shock as well as time to commencing CPR.

There is no scientific evidence yet that this particular app is proven to be beneficial; however, similar alerting systems have shown to improve survival rates. A text message-based alert system in the Netherlands showed that OHCA victims were 2.8 times more likely to survive if their arrest was attended by an alerted rescuer versus those that were not.11 Hopefully, similar findings will support the GoodSAM application when audited.

Another application is available in New Zealand that solely lists the locations of all nearby AED devices. ‘AED Locations’ is an app created by Gareth Jenkin, a resuscitation coordinator at Auckland City Hospital, which has over 9,000 AED locations listed.12 In this app, the option is also available to include the hours each AED is accessible, which could avoid wasting time in attempting to obtain a defibrillator.

4. Regular audits of AED applications and websites

As applications and websites expand, and AED lists become longer, the potential for inaccuracies grows as it becomes more difficult to regularly audit. In our study alone, there were errors in seven out of the original 50 listed (duplicate listings, no longer exist or inaccurate locations), 14% of our relatively small sample size. The responsibility has to be shared with those who list their device to maintain the accuracy of its location and accessible times, especially as these applications continue to grow.

5. Only show the available AEDs at the time the list is accessed

With all AED listing websites and applications, we strongly recommend that the times that the device is available should be added to the information accompanying the device. If possible, the lists should only show the AEDs that are truly available at the time the list is accessed.

6. Use of alternative AED sources and technologies

Alternatives to fixed location public AEDs have been investigated with the potential for success. The use of drones to deliver AEDs has the potential to reduce the time of first shock in OHCA. In Sweden, they recreated previous OHCA events and used drones to deliver an AED to those exact locations. They then compared the dispatch to arrival time of the paramedics that had arrived versus the drone. The median time from dispatch to arrival of the paramedics was 22:00 minutes vs 5:21 for the drone (P<.001). The drone was also quicker in all cases with a median reduction in response time of 16:39 minutes (P<.001).13 Even though this study showed large reductions in defibrillator arrival times, there would be multiple difficulties in implementing a system like this, including cost, training, weather and airspace restrictions to name a few.13

Other technologies that may be beneficial include battery-operated pocket defibrillators carried by members of appropriate services such as police officers.14 More research is needed to see if these are beneficial and practical in real life scenarios.

Limitations

In retrospect, there are additional questions that could have been asked during the study that would have been of value. The accurate number of AEDs that required lift access would have been of interest as it was a noticeable obstacle in some cases. An opportunity was missed to question if all AEDs were operational and up to date with servicing. Previous knowledge of the website could have been assessed by surveying the staff members encountered. All would be valuable information in a re-audit in the future or a similar study in another city.

Conclusion

During office hours there is a reasonable number of accessible AEDs in Hamilton. Access to public AEDs is limited outside office hours, with only 7% of AEDs available 24 hours, seven days a week. This is mainly due to restrictions to access. Simple measures could increase availability and public awareness of this life-saving equipment.

Summary

Abstract

Last year, there were 2,000 out-of-hospital cardiac arrests (OHCA) in New Zealand, 74% received CPR but only 5.1% accessed an automated external defibrillator (AED). The average survival rate of OHCA is 13%. The aim of this study was to visit all 50 AED locations shown on www.hamiltoncentral.co.nz to assess their true availability and visibility to the public in the event of an OHCA.

Aim

Method

All premises were visited and the first staff member encountered was asked if they were aware an AED was onsite, its location, hours of availability, if restricted access applied and whether it had been used.

Results

Of the 50 locations, three sites no longer exist and two AEDs were listed twice. Therefore, only 45 AEDs exist. Two sites had grossly inaccurate locations. Three AEDs (7%) were continuously available. Nine AEDs were accessible after 6pm at least one day of the week. Thirteen AEDs were available on weekends; however, five required swipe card access. None of the AEDs were located outdoors.

Conclusion

ar fewer than 50 listed AEDs are freely available to the public, especially after 6pm and on weekends. Lack of signposting and restrictions to access would lead to delayed defibrillation. This important health issue needs addressing.

Author Information

Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton;-Janice Swampillai, Electrophysiologist, Waikato DHB and Senior Lecturer Waikato Clinical School, University of Auckland, Auckland; Martin K Stiles, Director of Cardiac Electrophysiology, Waikato Hospital and Waikato Clinical School, University of Auckland, Auckland.

Acknowledgements

We would like to acknowledge Dr Tammy Pegg, Nelson Marlborough Hospital, for her help with the concept of the audit.

Correspondence

Dr Peter A O Callaghan, Cardiology Registrar, Cardiology Department, Waikato DHB, Hamilton.

Correspondence Email

peter.o'callaghan@waikatodhb.health.nz

Competing Interests

Nil.

  1. Dicker B, Oliver V, Tunnage B. (2018) Out-of-Hospital Cardiac Arrest Registry Annual Report 2017/2018, New Zealand: The St John New Zealand Registry Group.
  2. Capucci A, Aschieri D, Piepoli MF, et al. Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation. Circulation. 2002 Aug 27; 106(9):1065–70.
  3. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015; 372:2307–15.
  4. Jost D, Degrange H, Verret C, et al. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010; 121:1614–22.
  5. Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015; 95:81–99.
  6. Delhomme C, Njeim M, Varlet E, et al. Automated external defibrillator use in out-of-hospital cardiac arrest: Current limitations and solutions. Arch Cardiovasc Dis. 2019 Mar; 112(3):217–222.
  7. Sun CL, Demirtas D, Brooks SC, et al. Overcoming Spatial and Temporal Barriers to Public Access Defibrillators Via Optimization. J Am Coll Cardiol. 2016 Aug 23; 68(8):836–45.
  8. Clifford G. (2016) ‘How phone boxes are saving lives - and where to find them’, Irish Independent. 10th November, online article. (accessed 07 May 2019).
  9. Image: Maven Services. Heart of Killarney. http://heartofkillarney.ie/fossa/ (accessed 07 May 2019).
  10. Smith CM, Wilson MH, Ghorbangholi A, et al. The use of trained volunteers in the response to out-of-hospital cardiac arrest - the GoodSAM experience. Resuscitation. 2017 Dec; 121:123–126.
  11. Pijls RW, Nelemans PJ, Rahel BM, et al. A text message alert system for trained volunteers improves out-of-hospital cardiac arrest survival. Resuscitation. 2016 Aug; 105:182–7.
  12. AED Locations. AED Locations. http://aedlocations.co.nz/about/ (accessed 07 May 2019).
  13. Claesson A, Bäckman A, Ringh M, et al. Time to Delivery of an Automated External Defibrillator Using a Drone for Simulated Out-of-Hospital Cardiac Arrests vs Emergency Medical Services. JAMA. 2017 Jun 13; 317(22):2332–2334.
  14. Radcliffe Cardiology. FRED Easyport. http://www.radcliffecardiology.com/products/fred-easyport (accessed 05 May 2019).

Contact diana@nzma.org.nz
for the PDF of this article

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