Automatic defibrillators raise questions about workplace use

AAOHN issues warning to nurses about training, liability issues

Automatic external defibrillators (AEDs) offer what seems an incredible step forward for first aid in the workplace - an instrument for restarting the heart that can be kept on hand and used by just about anyone. The potential for improving the response to cardiac events is tremendous, but there also are some questions occupational health providers should consider before using the devices or recommending them to clients.

The uncertainties became more prominent recently when the American Association of Occupational Health Nurses (AAOHN) in Atlanta issued a position statement cautioning its members not to adopt the use of AEDs without taking a close look at the unanswered questions and the liability risks. (See the AAOHN statement, p. 108.) Legal experts tell Occupational Health Management that even if the devices offer improved emergency care to cardiac arrest victims, they could substantially increase the risk of a lawsuit resulting from that aid.

At this point, critics are not saying that AEDs should be avoided. Indeed, even those raising questions about the devices praise the idea of bringing user-friendly defibrillation to the workplace. But, like most medical devices with the potential to do harm if misused, experts are advising occupational health providers to look closely at the need for training and a comprehensive policy on the use of AEDs before approving the purchase order.

OH providers will bear the responsibility of making sure AEDs are incorporated correctly in the workplace, and they should play a major role in deciding whether to incorporate them at all, says Debra Olsen, MPH, RN, COHN-S, an instructor at the University of Minnesota School of Public Health and deputy director of the Midwest Center for Occupational Health and Safety, both in Minneapolis. Olsen also is a member of the AAOHN board of directors and was involved in creating the association's position statement on AEDs.

"Occupational health nurses are going to be the ones that people look to for coordination of these services because we are in a unique position," she says. "These devices are a fairly new development in health care, so nurses will have to do some research and seek some advice before deciding how to proceed."

AEDs deliver shocks to restart heart

AEDs are designed to deliver sophisticated emergency care to those suffering from sudden cardiac arrest, providing the same electrical shock defibrillation that was once available only in a fully equipped medical center or from paramedics. Sudden cardiac arrest kills about 350,000 people a year, with some medical authorities estimating that the chance of surviving an episode is less than one in 20. Many of those deaths could be prevented, doctors say, if defibrillation were administered almost immediately, without having to wait for paramedics or arrival at an emergency department.

There are several causes of sudden cardiac arrest, but the most common is ventricular fibrillation, in which the electrical signals that normally cause the heart to beat with a regular rhythm instead become random and leave the heart muscles quivering with no regularity. Victims fall unconscious almost immediately and can die within minutes.

When cardiac arrest is caused by ventricular fibrillation, defibrillation with an electric shock administered to the heart often can cause the heart to resume a normal rhythm. Successful resuscitation is most likely if the defibrillation is administered within the first 10 minutes or so of cardiac arrest. After four minutes, every minute of delay before defibrillation reduces the chances of survival by about 10%.1 The importance of early defibrillation was emphasized in 1990 when the American Heart Association created its "Chain of Survival" recommendations for responding to sudden cardiac arrest:

r Step one - early access to care by calling 911.

r Step two - early cardiopulmonary resuscitation.

r Step three - early defibrillation.

r Step four - early institution of advance life support.

Though the need for early defibrillation is well established, it is not always available, even if emergency medical care arrives on the scene quickly. Only 50% of ambulances, 15% of first-response fire department vehicles, and less than 1% of police vehicles are equipped with defibrillators, according to information supplied by the maker of an AED, Heartstream in Seattle.

Part of the problem in getting early defibrillation to cardiac arrest victims: It is a major form of treatment that must not be taken lightly. A tremendous electrical shock is delivered to the patient; if done incorrectly, the patient, as well as bystanders, can be seriously injured. Until recently, the use of a defibrillator required extensive training and could be used only by a physician or highly trained paramedic. Technological advances have allowed the creation of automatic defibrillators with the ability to take on so much of the decision-making process that even lay people can be trusted to use them. That is a promising development that raises many questions for occupational health providers.

The newest generation of defibrillators solves some problems that kept previous models from being practical in the workplace. Typical defibrillators were large and cumbersome, weighing as much as 25 pounds and costing about $7,000. The devices also required extensive maintenance to make sure that the unit was always properly charged and ready for use.

Heartstream has developed a portable, user-friendly model that is highly compact and costs about $4,000. Named the ForeRunner, the Heartstream AED can deliver about 100 shocks or operate for five hours before needing new batteries. It is specifically designed for use by nonphysicians. Even though the manufacturer recommends that it be used by first responders trained in the use of the device, it also notes that untrained laymen have used the AED successfully. The AED weighs less than 4 pounds and is roughly the size of a hardcover book. The device is designed to be rugged and requires no maintenance for long periods of time.

Device tells user when to administer shock

The AED is designed to be extremely easy to use. When a person collapses from what appears to be sudden cardiac arrest, the user takes the AED's defibrillation pads from the sealed pouches that keep the adhesive, conductive gel on the pads moist. The pads are applied to the patient's chest as shown in a simple diagram on the AED unit and on the pads themselves. (See photos, p. 106 and at left.)

There are only two buttons and a display screen on the unit. An "on/off" button starts the system and then the computer analyzes the patient's heart rhythm. If the AED determines that a shock is needed, an audible response says, "Shock advised. Charging. Stay clear of the patient." When it is ready to deliver the shock, the prompt states, "Deliver shock now." The user then presses the other button on the unit to deliver the shock. If the patient's heart rhythms do not require defribillation, the prompt will state, "No shock advised," and the shock button will not be activated.

Simplicity appeals to workplaces

The simplicity of the AED, along with the dramatic increase in survival rates possible with early defibrillation, make the devices quite attractive to employers and occupational health providers, especially those responsible for large workplaces in which sudden cardiac arrest is likely to occur at some time.

Several airlines have put AEDs on their long-distance flights. From a purely clinical and technical standpoint, there seems to be little doubt that the devices could be useful. But other concerns mean that occupational health providers should be very cautious in deciding to incorporate AEDS.

Olsen says several points require careful consideration. For instance, OH providers should assess the employee demographics of a workplace when deciding whether AEDs might be needed.

The type of industry could also be a factor. A first-responder program in the workplace improves the chances that you will have trained people to use the AED and will not have to start a training program from scratch. Does the workplace have reasonably fast access to paramedics in the community? If paramedic response is slow, that might be another reason to consider using AEDs.

"Our main concern is that if people use AEDs, they should develop the program in a systematic way," Olsen says. "There must be education, policy considerations, and a look at the efficacy of these devices."

The AEDs require special consideration because they are a means of allowing nonhealth care professionals to administer very advanced emergency care, Olsen warns. Unlike a fire extinguisher that is intended for anyone to use, for instance, the AED should be used only by those with training. The device operates in such a nearly foolproof way that any untrained layman could be successful with it, but Olsen explains that is not the best scenario. Having the AED used by the occupational health professional, who otherwise would not have access to a defibrillator, is best, and trained laymen are second best.

"It would not be out of line for lay workers to use the AED if necessary, but occupational health providers are responsible for coordinating their training beforehand," she says. "It's more than just buying them and putting them on first-aid stations."

When it comes to AEDs, health care professionals tend to have more unanswered questions than hard criticism. Kae Livsey, RN, MPH, public affairs manager with the AAOHN, says those questions were what prompted the organization to issue a warning to its members. Though it is unclear how many AEDs have been placed in workplaces, Livsey says the AAOHN has received many questions about them, and it is clear that employers are interested in AEDs for on-site emergencies.

"We're saying you really need to think about these before using them," Livsey says. "There is a lot of concern in terms of liability, for instance. The machine decides whether to fire or not, but historically, if you're defibbing someone, you're assuming responsibility for that action."

The questions regarding liability are perhaps the most troublesome for occupational health professionals, and because placing AEDs in the workplace is a new idea, there is little guidance. The liability risk has to be considered significant at this point simply because "this is unplowed ground," explains Greig Coates, MD, JD, an attorney with Mithoff and Jacks law firm in Austin, TX. He has previous experience on the clinical side of health care and now is a malpractice attorney.

"This is a well-intentioned idea, but I can easily see how this could be problematic," he says. "I'm sure that if the device manufacturer has a legal department worth its salt, it has shifted all the legal risk to the company purchasing the device instead of leaving it on itself. Otherwise it has bought itself a lot of trouble, and I doubt that."

It is possible a business could be sued for not having an AED available, but that is unlikely in a typical workplace because AEDs are still new to occupational health. Lawsuits for not having an AED available are more likely in unusual circumstances such as on a passenger airline or a cruise ship, where paramedics and quick access to emergency care are unavailable.

Coates emphasizes it would be a mistake, both medically and legally, to simply put a number of AEDs in the workplace and inform employees that these easy-to-use devices should be employed if someone appears to be in cardiac arrest.

Users could fear being shocked by device

Don't underestimate how many questions could arise when training first responders or other laymen to use an AED, he cautions. In particular, some people could be afraid of electrical shocks, for instance, and be reluctant to administer CPR or other necessary care while the patient is hooked up to the AED. That could turn the AED into a real disservice to the person needing care, Coates says.

And even though the AED should not fire if the shock is not needed, employing them without adequate education could delay other appropriate care while responders wait for the AED and then wait to find out that no shock is needed. Thorough education, even for such an apparently foolproof device, is an absolute necessity, he says.

"If everyone knows you have these fancy items at the first-aid station, but they don't know much else, they're going to pull them out every time someone goes down," Coates says. "When all you have is a hammer, everything looks like a nail."

Reference

1. Eisenberg MS. Cardiac arrest and resuscitation: A tale of 29 cities. Annals of Emerg Med 1990; 19:179-186.