Apr. 10, 1998 DALLAS, April 7 -- When the heart stops, help is needed immediately. But in many states, legislative barriers that restrict the use of medical devices to re-start the heart may inadvertently lead to thousands of deaths each year, according to a "special report" in today's Circulation: Journal of the American Heart Association.
The report's authors say that greater availability of public access defibrillation (PAD) -- which refers to a treatment for out-of-hospital sudden heart stoppages through use of automatic external defibrillators (AEDs) by the public or by other nonmedical personnel -- may be economically attractive and save as many as 24,000 lives each year.
Defibrillation uses electric "shocks" to re-start the heart. AEDs have paddles that are pressed against the chest to deliver the shocks that revive the heart. For each minute that passes after cardiac arrest, there is a 10 percent reduction in the chance of survival.
Even with this information, the questions surrounding PAD are significant. Who should use AEDs? If an average person without medical training uses an AED to revive someone and fails, is he or she liable for the death? Is a person trained to use an AED fails to do so is he or she liable for negligence? Where should AEDs be placed? How much does it cost?
In a 1996 poll of state emergency medical system (EMS) directors, only 27 states permitted non-emergency first responders to use AEDs. Only six states -- California, Florida, Maine, Maryland, North Dakota and Texas -- allowed the lay public to use AEDs.
"The common sense is still ahead of the science," says Joseph P. Ornato, M.D., a member of the American Heart Association's emergency cardiac care committee and a co-author of the report. "The more we show that this is not such a scary concept, the harder it's going to be for naysayers to argue. Common sense may carry the day to help some states to move forward on changing these 'Good Samaritan' laws."
"Good Samaritan" laws refer to legislation allowing people to help others in emergency medical situations so long as a "good faith" effort is made to save a life.
To make early access to defibrillation possible, the AHA says it's essential that a defibrillator be immediately available to emergency personnel responding to a cardiac arrest.
"There are two ways of expanding defibrillation," says the report's lead author Graham Nichol, M.P.H., M.D., assistant professor of medicine at the University of Ottawa, Ontario, Canada. "We can train and equip police or members of the public."
The researchers suggest that implementation of PAD in an urban center in the United States could be economically attractive. They call for a thorough clinical trial to assess the effectiveness and cost-effectiveness of PAD.
In addition, they say that AEDs should be distributed at specific sites where people often go into cardiac arrest, such as public places where there are large numbers of people -- airports, casinos, amusement parks and stadiums for example.
According to the researchers, the incremental cost involved with PAD is similar to other common medical treatments.
"You have to compare this with other efforts to improve survival," says Myron Weisfeldt, M.D., a co-author of the report and a past president of the American Heart Association. "We manufacture about 10 million automobiles each year and seat belts add $200 to the cost of building them. Studies say that seat belts save about 2,000 lives a year. It costs about $2 billion a year to put seat belts in cars and it saves about 2,000 lives. That's a million dollars per life saved.
"With public access defibrillation, if we took $2 billion in one year and bought AEDs, we'd have over a million, or 1 defibrillator for every 300 people. You can view one defibrillator per 300 people as likely improving survival by 5 percent. The cost per life saved is around $30,000."
According to the researchers, even though a standard EMS system has a lower cost per patient, PAD is still an economically viable solution and its effects are likely to be additive to the results of a standard EMS system. Implementation of PAD by members of the public cost $44,000 per additional quality-adjusted life year and implementation by police cost $27,000 compared to a standard EMS system. A quality-adjusted life year is a term used to define the life-extending capabilities of a medical procedure.
"We usually consider health programs that cost less than $50,000 per quality adjusted life year to be economically attractive," says Nichol.
The researchers state in their report that the implementation of PAD for the lay public could save greater than 4,000 lives and the use of defibrillation by police could save an additional 20,000 lives annually.
Recent activity in state legislatures shows that there is movement to expand access to AEDs. In Florida, legislation was recently signed into law that allows an AED to be used by any person for the purpose of saving the life of an individual having a cardiac arrest. The Florida state Good Samaritan law was also amended to require that those who use the AEDs in "good faith" to give emergency care will not be held liable for any damages. Similar types of laws have been discussed in several other states.
Other co-authors of the special report on cost-effectiveness include A. Hallstrom, Ph.D.; B. Riegel, D.N.Sc.; I. Stiell, M.Sc, M.D.; T. Valenzuela, M.P.H., M.D.; G. Wells, Ph.D. and R.D. White, M.D. Additional information can be found in another special report on AEDs authored by Sidney C. Smith, Jr., M.D. and Richard S. Hamburg, M.P.A. in this issue of Circulation: Journal of the American Heart Association.
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