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Squad Goals: Moving the Needle on Sudden Cardiac Arrest Requires a New Model
Sudden cardiac arrest (SCA) is the third-leading cause of death in the United States and, for many reasons, one of the most challenging public health issues for our nation. According to a recent National Academy of Sciences Institute of Medicine study, upwards of 395,000 people experience SCA outside of hospitals each year in the United States, equivalent to the population of New Orleans. But nationally, despite decades of awareness initiatives, preventative programs, and treatment innovations, less than 6 percent of these people survive, a frightening number that hasn’t changed in 30 years. That's why it's time for an "SCA response squad" model.
The medicine of SCA is well known. It is the abrupt loss of heart function that most often occurs when the electrical impulses in the heart become chaotic (known as ventricular fibrillation), causing it to suddenly stop beating normally. The condition is 100 percent fatal if not treated quickly.
And SCA is very much a treatable condition. Two therapies—cardiopulmonary resuscitation (CPR) and defibrillation—delivered in the first minutes after SCA occurs can have a profound impact on survival. The faster CPR and AED use happen, the higher the chances of survival. Unfortunately, this help rarely arrives in time. Here are some of the reasons why.
- Lack of public awareness and understanding of what SCA truly is—and what it isn't: Nearly 50 years after coming to public consciousness, both the media and the public still often confuse sudden cardiac arrest (a cardiac electrical problem, which can be helped by timely bystander CPR and AED use) and a "heart attack" (a cardiac plumbing problem that causes inadequate flow of oxygen-rich blood to the heart, which requires the intervention of medical professionals). This confusion makes potential bystanders unclear on what can and should be done.
- Low bystander CPR rate: Over the past 30 years, billions of dollars have been spent formally training millions of people in CPR. Yet, only about 26 percent of SCA victims receive bystander CPR today. Factors contributing to persistently low CPR rates include lack of awareness about SCA and how to help, lack of confidence in the ability to help, fear that trying to help will make the person’s condition worse, and concerns about legal liability. And while those billions spent have also aimed to alleviate these very fears, they persist.
- Low AED use rate: Less than 4 percent of SCA victims are treated with a bystander-used AED before emergency medical services (EMS) arrives. One reason for this is the critical U.S. AED shortage. An estimated 4 to 5 million AEDs have been sold in the United States since the 1990s, which is great progress. But more than 30 million are needed to ensure an AED will be reasonably close to most people experiencing SCA in public settings. Other factors include lack of general bystander knowledge about what an AED is and what it is used for, inability of bystanders to quickly locate an AED in the event one is nearby, a low percentage of bystanders willing to use an AED, and, again, that pesky fear of legal liability.
These factors are well known in the industry, and many people have written about them in books, journal articles, public relations materials, social media, and elsewhere for years. The real question is: If we know all this, why can't we save more than 6 percent of the people who experience SCA in public settings each year? The answer is complicated and requires thinking about the problem in new and different ways.
Clearly defining the requirements of an out-of-hospital SCA response system is the first step toward meaningfully improving SCA survival rates. The focus here is on workplace and community settings rather than the home or hospital. Let’s start with the key characteristics of frequency, time, people, and equipment:
- Frequency: In the aggregate, SCA happens often, striking thousands of people every year. However, predicting the precise locations where SCA will occur is impossible. On a per location basis (e.g., a health club, shopping mall, office, warehouse, manufacturing plant, school, place of worship, coffee shop, grocery store, etc.), a single SCA episode can be expected once every 10 to 40 years. So, while infrequent for any given location, being unequipped with an AED when SCA strikes is a virtual death sentence for the victim. This means lots more locations still need to put SCA response systems in place.
- Time: When SCA strikes, the clock starts ticking. CPR and defibrillation must happen in the first minutes after SCA occurs to be effective. That said, because SCA response systems rely on non-medical people, in settings not primarily focused on emergency medical services, there are limits on how quickly we can reasonably expect bystanders to react.
- People: Lots of SCA responders must be available to provide CPR and retrieve and use AEDs. But the people who choose to help in SCA emergencies are volunteers who have no legal obligation to act (whereas professional emergency medical responders generally do). As a result, they must be trained, aware, empowered, and legally protected if we expect them to step into the breach.
- Equipment: If SCA victims are to receive the benefits of defibrillation, AEDs must be nearby in the places SCA events occur. How nearby? Because defibrillation must be delivered within 5 minutes or less to have a positive impact on survival, an AED has a maximum coverage area of 283,000 square feet—about the size of five football fields. Since we don't know where SCA will occur, we need millions more AEDs than are found in workplace and community settings today.
Strategies Most Likely to Improve Survival Rates
With these characteristics in mind, what strategies can be employed that are most likely to improve aggregate SCA survival rates? Here are some suggested examples:
- Rethink the notion of training: A volunteer "SCA responder squad" is needed to ensure someone is almost always nearby who feels ready and willing to help. Today's emphasis is on formal CPR and AED training, but less than 5 percent of the U.S. public is formally trained due to time and cost barriers. This leaves most SCA victims without the potentially life-saving interventions they need. Adding a large-scale, informal "training" and empowerment model to the mix—reinforcing that anyone can help—and leveraging online training tools and streaming media have the potential to build the capacity for community response to meet what SCA demands. The CPR quality in this model admittedly won't be perfect (it isn't now, even under the formal training approach), but for the three out of four SCA victims who don’t get CPR now, less-than-perfect CPR is much better than none.
- Legally require AED placements: In the absence of legislative mandates, organizations generally have no obligation to buy and place AEDs. Only two states (Oregon and Rhode Island) require AEDs in many public locations. Targeted mandates requiring AEDs in places such as health clubs, schools, government buildings, and the like can be found in only a few states. As a result, most AEDs have been placed in public settings voluntarily, but in relatively low numbers. The only way to accelerate AED placements to the numbers needed is for legislatures to pass broad mandates. Yes, this has financial implications for organizations of all sizes, but they are far less than the cost of lawsuits filed as a result of not making AEDs available in the event of an SCA. And while structure fires are far less common than SCA, we long since abandoned the debate over whether fire extinguishers are a necessary expense. They are mandated and, therefore, universally available. We should learn from this.
- Fix Good Samaritan immunity laws: Contrary to popular belief, existing Good Samaritan immunity laws offer very little protection to the organizations and people involved in SCA response programs. Legitimate fear of legal liability (Google "heart attack lawyers," and you'll quickly understand) and the lack of solid legal protections are significant reasons why many organizations don't have AEDs, and so, few people are willing to help when SCA strikes. State legislators have the power to fix this. We need to encourage them to do so.
- Recognize that SCA response is about logistics as much as medicine: Properly preparing for and responding to SCA emergencies is largely a logistics problem. The goal is to have enough people and equipment in place and deploy those resources quickly once SCA is recognized. This requires comprehensive operating policies that ensure an organization is prepared for and performs well when SCA strikes. EMS has made great strides in this effort, but they alone can't solve this massive community challenge.
Putting these and other related strategies in place doesn't guarantee we’ll move the SCA survival needle. But they are worth a try. After all, the needle has stayed stubbornly immovable despite repeated efforts over the past 30 years.
So, what are our squad goals? Let's strive for a 50/50/5 "SCA response squad" model—a 50 percent rate of bystander CPR, 50 percent rate of public access AED use, and enough AEDs so that defibrillation can be delivered within 5 minutes for most SCA victims. If we achieve this much, we're bound to finally get that stubborn needle to budge.
Rapid Access to CPR and AEDs Makes SCA a Treatable Condition
Cardiopulmonary resuscitation (CPR) and defibrillation, if delivered in the first minutes after SCA occurs, can have a profound impact on survival from sudden cardiac arrest. CPR involves compressing the chest (and, therefore, the heart), which helps keep oxygen in the blood and the heart primed for defibrillation. Automated external defibrillators (AEDs) are medical devices that send an electrical current through the heart muscle (defibrillation) to restore a normal heartbeat. AEDs, when used quickly and together with CPR, can help a person experiencing cardiac arrest regain a normal heartbeat and survive. The faster CPR and AED use happen, the higher the chances of survival.
People of all ages and ethnicities experience SCA without warning. Seventy percent of out-of-hospital SCA events occur in private homes. Among the remaining 30 percent, it is impossible to predict who, where, or when SCA will strike. Some are surprised to learn that SCA strikes approximately 6,000 young people each year. In all, that means nearly 120,000 people each year—more than 300 each day— are at risk of dying from cardiac arrest in workplace and community settings where volunteer bystanders could potentially step in to help save a life.
For more information and resources on SCA, visit the Sudden Cardiac Arrest Foundation at www.sca-aware.org.
This article originally appeared in the October 2018 issue of Occupational Health & Safety.