CPR and AEDs—Two Important Acronyms for Your Workplace First Aid Program

There are still scenarios where the AHA strictly recommends conventional CPR.

• By Mike Stearns
• Jun 01, 2016

Most are familiar with cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs), but occasionally there’s confusion when it comes to incorporating these two lifesaving tools into a workplace first aid program. Just what are the Occupational Safety and Health Administration requirements? What's considered sufficient CPR training? Is training responders in compression-only CPR okay? And just where do AEDs fit in a first aid program? Let's explore these questions a bit.

When it comes to OSHA's requirements, the answers are found in a couple of locations. There are a few hazard-specific standards that require employers to have individuals trained in resuscitation as a component of their first aid response plans. The standards are: Permit-required Confined Spaces, 29 Code of Federal Regulations (CFR) 1910.146(k)(2)(iii); Logging Operations, 29 CFR 1910.266 (Appendix B); Electrical Power Generation, Transmission, and Distribution, 29 CFR 1910.269(x); and Qualifications of Dive Team, 29 CFR 1910.410(a)(3).

For employers not covered by these standards, OSHA addresses Medical Services and First Aid for general industry in 29 CFR 1910.151, for construction in 29 CFR 1926.50, for longshoring in 29 CFR 1918.97, for marine terminals in 29 CFR 1917.26, and for shipyard employment in 29 CFR 1915.87. Unlike the hazard-specific standards, these standards do not contain verbiage requiring employers to have someone trained in CPR on site, nor do they make reference to AEDs.

In a Jan. 16, 2007, interpretation OSHA provides clarity around its position on CPR in a workplace first aid program. The interpretation states, "OSHA recommends, but does not require, that every workplace include one or more employees who are trained and certified in first aid, including CPR." OSHA refrains from requiring all employers to have someone trained in CPR because, as they discuss in the interpretation, the primary goal is to ensure injured employees have prompt access to emergency medical treatment. If the employer can demonstrate that there are emergency medical services within a "near proximity" of the workplace, then that would take the place of having someone trained in CPR on site.

That same interpretation elaborates on what OSHA considers near proximity. It states, "Medical literature establishes that, for serious injuries such as those involving stopped breathing, cardiac arrest, or uncontrolled bleeding, first aid treatment must be provided within the first few minutes to avoid permanent medical impairment or death. Accordingly, in workplaces where serious accidents such as those involving falls, suffocation, electrocution, or amputation are possible, emergency medical services must be available within 3-4 minutes, if there is no employee on the site who is trained to render first aid. OSHA exercises discretion in enforcing the first aid requirements in particular cases. OSHA recognizes that a somewhat longer response time of up to 15 minutes may be reasonable in workplaces, such as offices, where the possibility of such serious work-related injuries is more remote." 

What OSHA is saying in regard to CPR is that they believe it's a really good idea for all employers to have someone trained on site when there is a potential for serious injuries involving stopped breathing, cardiac arrest, or uncontrolled bleeding. And employers covered under the hazard-specific standards must have an individual on site who is trained in first aid and CPR. 

What about having an AED available? In its "Best Practices Guide: Fundamentals of a Workplace First Aid Program," released in 2006, OSHA said that employers should consider AEDs when selecting first-aid supplies and equipment. The guide discusses the value of AEDs in improving the survival rates for victims of sudden cardiac arrest (SCA) and says all work sites are potential candidates for AED programs because of the possibility of SCA occurring and the need for timely defibrillation.

Sources for CPR Training
The aforementioned Best Practice Guide references the following three organizations by name as sources for first aid training: the American Heart Association (AHA), the American Red Cross (Red Cross), and the National Safety Council. It also gives employers additional flexibility by acknowledging that there are other nationally recognized organizations that offer training.

With OSHA allowing employers flexibility in choosing which organization they use for CPR training, is there any reason to pick one over another? The AHA and Red Cross are the two most widely utilized training agencies. To be compliant with OSHA standards, hands-on instruction and evaluation are required for certification. Both of these organizations offer two-year CPR certification for laypersons and health care professionals, with different options for renewal. 

Generally speaking, the AHA's programs are more geared toward health care professionals. It's a research organization in addition to being a provider of first aid training. And while the Red Cross does offer first aid trainings for those in health care, overall their trainings are more focused on the needs, and geared toward the understanding level, of the general public. They, like other CPR training providers, adhere to the guidelines established through the AHA.

Hands-Only CPR
While the standard adult CPR protocol from the major training providers remains 30 chest compressions followed by two breaths, the value of compression-only CPR has been gaining momentum during the past decade. Both the AHA and the Red Cross offer CPR training courses where compression-only is the primary form of resuscitation taught. The AHA first officially acknowledged compression-only CPR (sometimes referred to as CCR for cardiocerebral resuscitation) in 2008 when it released the following statement, "bystanders who witness the sudden collapse of an adult should dial 911 and provide high-quality chest compressions by pushing hard and fast in the middle of the victim's chest."

The AHA reports in its 2015 Hands-Only™ CPR Fact Sheet that "hands-only CPR has been shown to be as effective as conventional CPR for cardiac arrest at home, at work or in public. It can double or even triple a victim’s chance of survival."

Some health professionals believe that the success of the CCR can be attributed to the uninterrupted chest compressions providing a continuous supply of oxygenated blood to the brain. Additionally, for the majority of the population, there’s less reluctance to render aid when mouth-to-mouth contact is removed from the equation. The key to surviving SCA is receiving aid as soon as possible, and a simplified procedure like CCR may potentially provide bystanders with the confidence and comfort level to get involved quickly.

There are still scenarios where the AHA strictly recommends conventional CPR.  CPR with compressions is advised for infants and children who have not reached puberty, as well as for victims of drowning, drug overdose, or for people who collapse due to breathing problems.

Where Do AEDs Fit In?
AEDs are powerful lifesaving tools. In addition to OSHA, the American College of Occupational and Environmental Medicine (ACOEM) encourages their accessibility in the workplace. In its September 2012 position statement entitled "Automated External Defibrillation in the Occupational Setting," ACOEM stated, "Several studies have reported that for each minute of untreated cardiac arrest, the probability of successful rhythm conversion decreases by up to 10%, producing an equivalent per-minute-death rate. Conversely, survival rates as high as 90% have been reported when the collapse to defibrillation ('drop to shock') rate is within one minute."

ACOEM also references a study that looked at survival rates for out-of-hospital SCA. The study showed that overall victim survival to hospital discharge was 7 percent. The survival rate increased to 9 percent when a bystander provided CPR but no AED was used. When CPR was combined with the delivery of a shock from an AED, the survival rate increased to 38 percent.

With OSHA encouraging their use and studies documenting the life-saving impact that they provide, why are AEDs not more common in the workplace? Some may be reluctant to consider AEDs due to perceptions regarding costs and complexity to operate. It's true, when AEDs first became commercially available, they cost several thousand dollars and often required hours of training before responders became comfortable using them. Today, high-quality AEDs are less expensive than they once were and include simplified operation technology, as well as audio instructions, that assist those using the device during an emergency.

Also, many of the challenges that faced employers looking to purchase AEDs have been reduced. The AHA offers a guide called "Implementing an AED Program." It lays out the following nine easy-to-follow steps for those looking to add AEDs to their first aid program:

• Get medical oversight. The U.S. Food and Drug Administration (FDA) may require a physician's prescription to purchase an AED. The role of the physician varies depending on the size and other characteristics of the program.
• Work with local EMS. Most states require you to coordinate your AED program with local EMS to provide follow-up data to EMS after any use of the AED.
• Choose an AED. The AHA’s guide lists six different AED manufacturers that have been cleared by the FDA.
• Contact technical support. Make sure you have technical support when your AED needs it. Call the manufacturer's technical support number to learn about the type of support you will receive.
• Make sure program support is available. Some AED manufacturers provide help with program implementation.
• Place your AEDs in visible and accessible locations. Effective AED programs are designed to deliver a shock to a victim within three to five minutes after a person collapses. Use a three-minute response time as a guideline to help you determine AED needs and placement.
• Develop a training plan. AED users should be trained in CPR and the use of an AED.
• Raise awareness of the AED program. Provide awareness to all employees about the AED program.
• Implement an ongoing maintenance routine. A weekly or monthly visual inspection of the AEDs is important to ensure they are in working order. This regular inspection supplements the more detailed inspections recommended by manufacturers.

For employers concerned about assuming additional liability by bringing AEDs on site, the AHA points out that all 50 states now cover the use of the devices under Good Samaritan laws. The laws vary by state. The AHA suggests employers check their state's Good Samaritan law for specifics and also seek input from legal counsel as part of an AED program's groundwork.

This article originally appeared in the June 2016 issue of Occupational Health & Safety.