Second of two parts

Nurses find AEDs cost-effective and implement program for workplace use

Several workplace deaths in four years disturb nurse, prompt AED use

Four sudden cardiac deaths in four years were difficult enough for Dirk Wellbrock, RN, to accept as an occupational health nurse at the Hewlett-Packard plant in Vancouver, WA. But when paramedics responding to the incidents asked him why he didn't have an automatic external defibrillator (AED) to resuscitate the victims immediately, he wondered whether he was doing everything necessary to protect his workers.

After he looked into AEDs, Wellbrock decided that they were a necessary addition to the workplace. Though they were not required to meet the standard of care when the cardiac deaths occurred, and still aren't required in any sense, Wellbrock decided he had to get the AEDs to assure himself he was doing everything possible when confronted with a sudden cardiac emergency.

"They were typical cardiac events, with the people going down suddenly," he recalls. "One woman went down in a busy hallway that was not occupied for just a minute, and another was a man who went down after coming back from a break. We did everything we could, and the paramedics came and shocked them, but they couldn't be saved."

A third worker suffered cardiac arrest that also was not work-related, and a fourth incident involved a contract electrician who was electrocuted. There is no way to know if a quick response with an AED would have saved the workers. However, Wellbrock, who is extensively trained in coronary care in a hospital setting, says he never again wants to kneel over a fallen worker and know that he or she needs defibrillation that is many minutes away.

"I personally responded to three of those events and worked on the people who died," he says. "I don't want to be in that situation again, knowing what this person needs but unable to provide it."

Study shows AEDs are needed

It is becoming increasingly apparent that AEDs are necessary cost-effective first-aid devices for the workplace, according to Wellbrock and another nurse who recently introduced the devices to her large work site. They caution, however, that AEDs require a detailed system for their use.

The idea of using AEDs at the Hewlett-Packard site in Andover, MA, was first considered about a year ago. At that time, company officials asked Paula Smith, RN, BSN, COHN-S, the manager of occupational health services, to conduct a cost-benefit analysis and generally research whether AEDs would be a good addition to the workplace. In the end, she found that adding the devices would be a good move.

There were several reasons that company officials first considered AED use, she says. First, some leaders in the company had heard of AEDs being used on airplanes and in other settings, and wanted to know if their use would be feasible for protecting Hewlett-Packard employees. And since this division of Hewlett-Packard manufactures medical equipment, including hospital-type defibrillators, company leaders thought it might be a good idea for the company to have the latest first-aid equipment available. With about 3,000 workers on site in several buildings covering a million square feet of property, the company officials suspected that AEDs could significantly improve the response time to cardiac events, Smith says.

There also was a business strategy involved: Hewlett-Packard was considering the development of its own AED for sale, and the company wanted to use Smith's internal cost-benefit analysis as an indication of how appropriate the devices are for workplaces in general. About halfway through her research process, Smith learned that Hewlett-Packard was purchasing Heartstream in Seattle, the maker of the most well-known AED on the market. (See photo, above.)

No pressure from management

She says the company put no pressure on her to alter her research in favor of AED use, though officials are now pleased to show their own internal program as a way to implement AEDs. Smith's division does not manufacture AEDs; Heartstream is one of many high-tech manufacturers owned by Hewlett-Packard.

Smith had planned to recommend a competitor's AED for use in her Hewlett-Packard work site, but after the parent company purchased Heartstream, she decided to go with that product because she could get a substantial discount on the purchase of a Hewlett-Packard-related product.

AEDs deliver the same electrical shock defibrillation that used to be available only in a hospital or from highly trained 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 avoided if defibrillation were available more quickly. Even with an advanced 911 system in your community, 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 Heartstream.

The American Association of Occupational Health Nurses (AAOHN) in Atlanta recently issued a position statement cautioning its members that AEDs require some consideration before implementing them in the workplace. In addition to concerns about training and proper use, legal experts say AEDs could substantially increase the risk of a lawsuit. (For more on those concerns, see Occupational Health Management, September 1998, pp. 105-109.) Wellbrock and Smith say the AAOHN statement is overly cautious and doesn't take into consideration all the research that shows the effectiveness of AEDs.

It is up to occupational health providers to lead the way with AEDs, 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 AAOHN position statement on AEDs. She notes that employers may become excited about the possibility of adding AEDs to the workplace, but it is up to the occupational health professional to study whether they are appropriate and, if so, to introduce them in the correct way.

Examine need and cost-effectiveness

For Smith, one of the first steps in that process was to look at the need and cost effectiveness of having defibrillators in the workplace. After all, it is technically possible to have all sorts of sophisticated medical equipment in the workplace, but it is not always worth the expense and related obligations for upkeep and training. When the equipment significantly increases the chance of saving a life, the cost and related obligations become more worthwhile.

Smith already knew that her work site was huge - spread out with many buildings and thousands of workers. When she looked into the average response time from local emergency medical services, she found it would take about nine minutes to get paramedics to a cardiac arrest victim. Two minutes of that was the time required to get the paramedics to the victim's specific location once they stepped on Hewlett-Packard property.

"We have a very good emergency response from our community, but nine minutes is not fast enough for someone in cardiac arrest," Smith says.

Similarly, Wellbrock's site has about 2,200 people on two campuses, where they manufacture computer printers. The average response time for local paramedics is eight to 12 minutes.

"They might be here quicker than that, but you can't depend on it," Wellbrock says. "I have to look at in terms of whether this were my friend or mother working here. Would I feel OK that we didn't have AEDs here? No, I wouldn't."

Smith also worked with the state department of public health, which oversees local emergency medical services, to determine the best way to introduce AEDs to the workplace. Once she recommended AEDs to her employer and received approval, she continued working with the emergency services when implementing the program.

"That's a key point for anyone setting up an AED program. You need a good relationship with your local emergency medical services," Smith says. "You want to make sure your protocols sit well with the people who are responding next."

Once Smith's company approved the introduction of AEDs, the real work was only beginning. Because of the special discount on Hewlett-Packard products, she was able to purchase the AEDs for about $1,800 each instead of the normal price of about $4,000. But she needed 12 units to place throughout the property, so the company still had to shell out $21,600 for the devices. The more typical cost of 12 units would be $48,000.

Only for use by trained first responders

The AEDs were not intended for use by everyone at the work site, Smith says. The company already had a program of emergency first responders in the workplace, so the AEDs are seen as an additional tool for them to use before the local paramedics arrive. Even though the defibrillators are almost foolproof, Hewlett-Packard takes the position that they are sophisticated medical devices that should be used by people with appropriate training.

"Once we have more experience with our emergency responders using them, to see how easy they find it to use and how well the program works, we might decide it's OK to allow them to be used by less-trained people," Smith says. "I think that eventually anyone will be able to use it."

Restrictions on who can use the devices are driven partly by liability concerns, Smith says. Though anyone familiar with the devices knows that practically anyone could use them, the corporate exposure in a workplace demands that employers be more cautious and require training. Hewlett-Packard actually decided that using the devices would lower the liability for cardiac events in general.

Though AEDs are not standard in workplaces or the general community yet, Smith says she thinks the tide will turn on that issue soon. Once it does, employers will have to have AEDs in place to avoid charges of negligence.

Smith says the AEDs have been welcomed warmly by her first responders. (For more on how Smith introduced the AEDs in her workplace, see related story, below.)

"Our emergency first responders are excited to have them because it means they can do something in a cardiac arrest, " she says. "They understand the importance of defibrillating quickly, and the AEDs mean they can really do something to help their fellow worker not just be in a holding pattern waiting for help to arrive."