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Arrhythmias and sudden death

ORIGINAL ARTICLE

Public knowledge and confidence in the use of public access defibrillation Ben Brooks,1 Stephanie Chan,1 Peter Lander,1 Robbie Adamson,1 Gillian A Hodgetts,2 Charles D Deakin2,3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ heartjnl-2015-307624). 1

University of Southampton, Southampton, UK 2 South Central Ambulance Service, Otterbourne, UK 3 NIHR Respiratory BRU, University Hospital Southampton, Southampton, UK Correspondence to Professor Charles D Deakin, South Central Ambulance Service, Southern House, Otterbourne, SO21 2RU, UK; [email protected] Received 5 February 2015 Revised 31 March 2015 Accepted 7 April 2015 Published Online First 29 April 2015

ABSTRACT Introduction Growing numbers of public access defibrillators aim to improve the effectiveness of bystander cardiopulmonary resuscitation prior to ambulance arrival. In the UK, however, public access defibrillators are only deployed successfully in 1.7% of out-of-hospital cardiac arrests. We aimed to understand whether this was due to a lack of devices, lack of awareness of their location or a reflection of lack of public knowledge and confidence to use a defibrillator. Methods Face-to-face semistructured open quantitative questionnaire delivered in a busy urban shopping centre, to identify public knowledge relating to public access defibrillation. Results 1004 members of the public aged 9–90 years completed the survey. 61.1% had been first aid trained to a basic life support level. 69.3% claimed to know what an automatic external defibrillator was and 26.1% reported knowing how to use one. Only 5.1% knew where or how to find their nearest public access defibrillator. Only 3.3% of people would attempt to locate a defibrillator in a cardiac arrest situation, and even fewer (2.1%) would actually retrieve and use the device. Conclusions These findings suggest that a lack of public knowledge, confidence in using a defibrillator and the inability to locate a nearby device may be more important than a lack of defibrillators themselves. Underused public access defibrillation is a missed opportunity to save lives, and improving this link in the chain of survival may require these issues to be addressed ahead of investing more funds in actual defibrillator installation.

INTRODUCTION

To cite: Brooks B, Chan S, Lander P, et al. Heart 2015;101:967–971.

For the 30 000 individuals suffering a sudden out-of-hospital (OOH) cardiac arrest in the UK each year where attempts at resuscitation are appropriate,2 survival is poor, with current rates averaging no more than 7–10%.3 Many of these events are potentially survivable, as evidenced by the best systems of care that achieve comparable survival rates in excess of 20% (for all rhythms)4 5; a key component of this improved survival is the more rapid delivery of basic life support with defibrillation, whether by bystanders or trained responders. In the UK, ambulance performance targets require a response to 75% of cardiac arrest calls within 8 min, but with mortality increasing 10% for every minute’s delay,3 only a minority of patients are potentially salvageable by the time ambulance crew arrive on scene. The first three of the four links in the Chain of Survival (early

recognition and call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation)2 all involve first aid that can be given by bystanders prior to ambulance arrival. Improving bystander resuscitation rates is recognised in the recent Cardiovascular Disease Outcomes Strategy as a priority area for improved care.1 The addition of public access defibrillation (PAD) to bystander CPR has been shown to double overall survival,6 with survival for those with shockable rhythms as high as 53%.7 PAD has been shown to be safe and effective, when used by members of the public even with minimal or no first aid training,8 and national PAD programmes have aimed to make public access defibrillators available in areas of high footfall such as shopping centres and transport hubs where they are likely to see service. There are three requirements for PAD programmes to be successful: first, that there are sufficient devices placed in the community; second, that the location of the public access defibrillator is known or easily identified in the case of an emergency; and third, that the public have sufficient knowledge and confidence to use the device. All three requirements must be met for the delivery of effective bystander defibrillation. National schemes to date have generally focused on the first of these requirements, and the introduction of public access defibrillators has now been underway for more than a decade9 with significant, although unknown, numbers of public access defibrillators available across the UK. The optimal public access defibrillator density is unknown but has often been considered adequate to meet the needs to the community. However, recent studies have shown that despite significant government and community investment, defibrillators are only deployed in 0.3210–1.7%9 of OOH cardiac arrests. Whether this is a reflection of a physical lack of devices or related to identifying the location of the nearest automatic external defibrillator (AED) or lack of public confidence and knowledge to use the device is unknown. It is important to understand the reasons for these disappointingly low deployment rates in order to guide future health strategy and to improve the effectiveness of PAD to strengthen the chain of survival. We therefore undertook a survey of 1000 members of the public, specifically to ascertain both whether they were able to identify the location of their nearest public access defibrillator and to investigate public knowledge and confidence in PAD.

Brooks B, et al. Heart 2015;101:967–971. doi:10.1136/heartjnl-2015-307624

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Arrhythmias and sudden death METHODS Study population In the 2011 Census, the resident population of Southampton was 236 900. The city’s population had a higher percentage of students aged 15–24 years (20%) compared with the national average of 13% and the median age group was 20–24 years. In 2011, 77.7% of residents recorded their ethnicity as white British, with European, Indian and Chinese populations comprising a significant proportion of the remaining population.11 The study was undertaken outside WestQuay, a busy Southampton shopping centre between 09:00 and 17:00 on both weekdays and weekends. WestQuay has an area of 800 000 square feet (70 000 m2) of retail space, containing 150 shops. It is visited by approximately 60 000 people on an average day, but as many as 90 000 at peak times.

Study design Members of the public were randomly approached by researchers (one of five medical students) and invited to take part in a short questionnaire (see online supplementary appendix 1). The study aimed to recruit a convenience sample of 1000 members of the public of all ages. We did not set a lower age limit and also questioned children if they volunteered to participate. Participants were only excluded if they had insufficient English or competency to participate and were excluded at the time of recruitment. In order to minimise bias, all individuals in the shopping complex were considered potential rescuers and formed the target population. The interviewers approached the nearest member of the public and aimed to be non-selective in their choice. We did not audit this selection process itself, but were assured that this protocol was adhered to. Interviewers wore a tee shirt with the South Central Ambulance Service logo to distinguish themselves from other individuals or organisations that the public may have been reluctant to engage with. Responses were based on individual opinion and were not collaborative. After the interview was completed or declined, the next individual nearest to the interviewer was approached. Those agreeing to participate were presented with a semistructured open quantitative question set to identify public knowledge relating to PAD. The questionnaire (see online supplementary appendix 1) contained sections regarding first aid training, basic life support and defibrillator knowledge. The final question presented a scenario involving someone who had collapsed and was unresponsive. Participants were asked unprompted to describe step-by-step what they would do in order to evaluate their knowledge and abilities in a cardiac arrest scenario. The questionnaire was similar to a survey used to investigate public knowledge of first aid for OOH cardiac emergencies in Melbourne.12 No demographic data other than age group was collected. Having completed the survey, participants were offered leaflets directing them to current bystander resuscitation guidelines and a proportion (approximately 50%) were also invited to attend an emergency life support course specifically designed for this study, which would teach bystander CPR and defibrillation using AEDs.

Data analysis Each completed questionnaire was reviewed, the results extracted and collated to a database. These results were based on what had been recorded on the forms in writing by the researcher, the details of which were aimed to provide sufficient clarity to address the question that had been asked. Results were analysed with SPSS (V.17.0; SPSS, Chicago, Illinois, USA) using 968

descriptive statistical analysis. Continuous data ( participant age) are presented as mean (SD). Proportions are reported as percentage.

STROBE statement We have followed the STROBE recommendations (strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies) and checklist where appropriate.13

RESULTS Demographics and first aid training A total of 1004 responses were obtained between April and June 2014 from approximately 5000 people who were approached by our researchers. The questionnaire was completed in full by 1004 (100%) of respondents. Overall age range was 9–90 years, and the median age group was 20–39 years (60 years age). Of all respondents, 61.1% (613/1004) had been first aid trained to a basic life support level. The distribution of first aid training obtained by this population is shown in table 1.

Cardiac arrest knowledge In total, 79% (793/1004) of people reported that they would know what to do in a cardiac arrest situation (yes/no). Details of the actions that individuals would take were recorded as free text and tabulated below. No prompts were given. Results are shown in table 2 and are subdivided according to first aid training.

Defibrillator knowledge In total, 69.3% (696/1004) of people claimed to know what a defibrillator was and 26.1% (262/1004) reported knowing how to use one. Specific actions offered by those who stated they knew how to use a defibrillator, as well as first aider versus nonfirst aider comparisons, are shown in table 3. Only 5.1% (51/1004; first aid trained 7.0% (43/613) vs nonfirst aid trained 2.0% (8/391)) of people knew where or how to find their nearest public access defibrillator. Only 3.3% (33/ 1004; first aid trained 3.2% (32/1004) vs non-first aid trained 0.1% (1/1004)) of people would attempt to locate a defibrillator in a cardiac arrest situation, and even fewer (2.1% (21/1004); first aid trained 2.0% (20/1004) vs non-first aid trained; 0.1% (1/1004)) would actually retrieve and use the device.

First aid course Approximately 50% of the 1004 people who had completed the survey were invited to attend a local first aid course. Numbers were limited to 500 because of the capacity of the researchers to

Table 1 Location/source of training for those with first aid knowledge Location/source of first aid training School/college/extra-curricular Non-healthcare work Healthcare work Charities (St Johns/Red Cross) Military Doctor Other

21.5% (132/613) 50.9% (312/613) 12.5% (77/613) 10.6% (65/613) 3.3% (20/613) 0.5% (3/613) 0.8% (5/613)

Brooks B, et al. Heart 2015;101:967–971. doi:10.1136/heartjnl-2015-307624

Downloaded from http://heart.bmj.com/ on August 6, 2015 - Published by group.bmj.com

Arrhythmias and sudden death Table 2

Self-reported actions for cardiac arrest in first aiders versus non-first aiders

Shout for help Call 999 Check response Check breathing Commence CPR Locate defibrillator Apply and use defibrillator Continue CPR until ambulance arrives Compression rate 100–120/min Compression/breath ratio 30:2

First aider

Non-first aider

Total

40.8% 66.4% 50.4% 58.4% 55.0% 5.2% 3.3% 3.1% 4.6% 6.5%

22.8% (89/391) 61.0% (238/391) 20.5% (80/391) 20.8% (81/391) 20.0% (78/391) 0.3% (1/391) 0.3% (1/391) 0.5% (2/391) 1.5% (6/391) 0.5% (2/391)

33.8% 64.3% 38.7% 43.8% 41.4% 3.3% 2.1% 2.1% 3.4% 4.2%

(250/613) (407/613) (309/613) (358/613) (337/613) (32/613) (20/613) (19/613) (28/613) (40/613)

(339/1004) (645/1004) (389/1004) (439/1004) (415/1004) (33/1004) (21/1004) (21/1004) (34/1004) (42/1004)

CPR, cardiopulmonary resuscitation.

of a trained responder. This is comparable with a recent clinical study in the same geographic region that documented PAD use in only 1.7% of actual OOH cardiac arrests.9 Although when prompted more individuals claim to know the function and purpose of using a defibrillator,14 we believe that an unprompted question is a better indicator of an individual’s likely action in the event of an emergency. It is surprising that although one quarter of those questioned who claimed to know how to use a defibrillator, and therefore presumably knew why they were using it, so few would actually translate this into practical action. We also observed that only 5% of those questioned knew how to locate their nearest PAD, indicating that a major rate-limiting step in successful PAD was the ability to locate a device. There are a number of methods to locate a public access defibrillator, including personal local knowledge, assistance from security guards/staff in public areas, smart phone apps (eg, ‘AED Locator’) and dialling ‘999’ where some ambulance Trusts have rapid access to PAD databases and can give instructions as to the whereabouts of the nearest device. Subjectively, the UK does lag behind many other European countries in ensuring that public access defibrillators are clearly marked and highly visible. For example, in the shopping centre (WestQuay) where this study was conducted, there are two public access defibrillators, neither of which are marked and their location only appears known to security staff and some shop employees. Those without first aid training were unlikely to attempt to retrieve and use a public access defibrillator, and it is clear that although public access defibrillators are designed to be used safely by those with little or no training, previous first aid training is a prerequisite for successful use. A study from the Netherlands also identified that only a minority of individuals had sufficient knowledge and willingness

deliver the teaching if all those invited subsequently attended. The 2 h resuscitation course was scheduled to be run on two separate weekends at the local hospital where free car parking and refreshments were also to have been provided. Multiple methods to book a course were offered (email, phone, postal). Only two individuals replied positively to the RSVP, neither of whom turned upon the day.

Knowledge by age group Knowledge according to age group is presented with regard to cardiac arrest knowledge (table 4) and AED knowledge (table 5). We have not attempted to analyse any statistical difference between age groups as the study was not powered to enable us to draw any conclusions from this data.

Other Although the majority of respondents reported that they had been first aid trained, it was apparent that most training was not up to date with current recommendations in bystander CPR. There was global confusion among the public regarding recent changes to guidelines such as hands-only CPR versus CPR with rescue breaths, and compression rates and compression to breath ratios. Our data shows that first aid training increases only theoretical knowledge of basic life support and defibrillation, but does little for confidence in a cardiac arrest scenario.

DISCUSSION We have investigated the reasons why rates of PAD are so poor, even in areas where public access defibrillators are available. We have found that when faced with someone who had collapsed and was unresponsive, only 2.1% of the public would attempt to find and use a public access defibrillator prior to the arrival

Table 3

Self-reported actions for AED use in first aiders versus non-first aiders

Open AED Listen to and follow instructions Apply pads in correct area on chest Await analysis of heart rhythm Aware persons to be clear before shock Shocks patient Continues CPR should shock not be advised/successful

First aider

Non-first aider

Total

19.6% 28.2% 19.9% 8.3% 11.6% 14.8% 3.6%

6.2% 8.5% 6.4% 1.0% 2.8% 4.6% 0.0%

14.3% 20.6% 14.6% 5.5% 8.2% 10.9% 2.2%

(120/613) (173/613) (122/613) (51/613) (71/613) (91/613) (22/613)

(24/391) (33/391) (25/391) (4/391) (11/391) (18/391) (0/391)

(144/1004) (206/1004) (147/1004) (55/1004) (82/1004) (109/1004) (22/1004)

AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation.

Brooks B, et al. Heart 2015;101:967–971. doi:10.1136/heartjnl-2015-307624

969

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Arrhythmias and sudden death Table 4 Cardiac arrest knowledge by age group Age

Public knowledge and confidence in the use of public access defibrillation.

Growing numbers of public access defibrillators aim to improve the effectiveness of bystander cardiopulmonary resuscitation prior to ambulance arrival...
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