An evaluation of the Public Access Defibrillation (PAD) Demonstration

4.2 Appropriateness of the current model of PAD

Page last updated: August 2008

Stakeholders were asked about the appropriateness of the sites selected to participate the PAD Demonstration, and the appropriateness of the current PAD Demonstration model.

Stakeholders identified appropriate venues to be those with a large volume of people moving through regularly, or areas where previous sudden cardiac arrest events had occurred.

I think they are [at the appropriate sites]. Anywhere having a large collection of people moving through is a reasonable place to have a defibrillator – train stations, airport, shopping centres. (Stakeholder)

Where you have high volume, such as airports, over a period of years they will save lives … as long as there is someone gutsy enough to have a go at activating the unit. (Stakeholder)

Stakeholders also mentioned that the guidelines for the Australian PAD approach were based on those of the American Heart Association (the peak body driving PAD in the US), who were considered to be pioneers in the public access defibrillation field. It was perceived that through the PAD Demonstration, St John was seeking to place AEDs in appropriate areas. That is, locations where a cardiac arrest would be expected every two to five years, and where trained responders or bystanders to be able to use the AED would be available within three minutes.

The fact that St John had actively consulted with local ambulance authorities in identifying appropriate venues was also mentioned as a strength of the PAD program.

The roll-out was done as a consultative process [between St John and the state ambulance authority]. Our involvement gave it that local stamp of authority. (Stakeholder)
Stakeholders felt that appropriate sites had been selected for the PAD Demonstration. However, stakeholders noted that participation in the PAD Demonstration came down to enthusiasm from organisations at the local level. A number of organisations identified as appropriate sites (particularly large shopping centres) were resistant to the installation of AEDs. Stakeholders believed that this reluctance stemmed from an unfounded fear of litigation – that organisations were concerned that they would be liable if an AED was activated and there was a negative outcome for the patient.

Shopping centres just use that litigation as an excuse not to take it on. (Stakeholder)

It surprises me that major shopping centres are not getting involved because of litigation concerns. It's ludicrous. (Stakeholder)

As a result, some stakeholders were concerned that some installation sites had been selected more out of willingness to participate, rather than for being the most appropriate site for an AED.

I can see why some [smaller sporting clubs] would want to stick their hands up for [a free AED]. Even if it saves one life over ten years I can see that it would be worthwhile for them … But we have to look at the bigger question - where is the biggest bang for buck? They need to be rolled out in venues where they can make a difference. (Stakeholder)
These stakeholders identified a need for wider recognition that people have a better chance of surviving sudden cardiac arrest if AEDs are used.

Overall, the current PAD Demonstration was perceived by stakeholders as an appropriate way of establishing access to early defibrillation in Australia. However, the current model was not necessarily the most appropriate means for delivering a sustainable early defibrillation service in the long term.

It is the most intelligent way to start. (Stakeholder)
Appropriate installation sites have been selected for the PAD Demonstration. However some appropriate organisations feared litigation from negative AED outcomes and were reluctant to install AEDs.

4.2.1 First responder versus public access
4.2.2 Government funding for public access defibrillation

4.2.1 First responder versus public access

Stakeholders suggested that public access (defibrillation by anyone in the vicinity of the AED, trained or untrained) was not necessarily the most appropriate early access defibrillation model. Trained first responder defibrillation programs (with AEDs placed in easily accessible public areas for defibrillation by appropriately trained persons who have a duty of care to respond to a medical emergency) were believed to be a more appropriate and effective means of delivering early access defibrillation in public areas, than public access defibrillation.

Defibrillation alone is not enough. It is part of the whole picture: people need to know to call 000 not the doctor; know how to respond; and really be prepared to act – that is the importance of that additional CPR training. (Stakeholder)
Training familiarised first responders with the AED, provided the additional skills of CPR training and provided individual responders with a sense of reassurance in their ability to activate the AED. Stakeholders from both the National Heart Foundation and the Australian Resuscitation Council strongly emphasised the importance of combining CPR with AEDs to provide the optimum outcome for a cardiac arrest patient.

It is important to understand that the provision of AEDs is just one aspect in the uptake and preparedness of people to act… it's also the attitudinal phases of intervening in a medical emergency which need to be considered. (Stakeholder)

It is rare that, when someone collapse, you put an AED on, they are in a shockable rhythm, the AED gives a shock and then they just sit up in front of you. They [the patient] need a period of CPR. That period of CPR, particularly the chest impressions, is crucially important. (Stakeholder)

However, these stakeholders emphasised that public access defibrillation was better than no intervention at all, stating that defibrillation gives the best chance for survival, even if administered by an untrained bystander.

One stakeholder cautioned that to be sustainable, the PAD Demonstration must not solely rely on those initially trained as first responders. The training (in use of AEDs and CPR) needs to become standard organisational practice, to ensure that the knowledge is not lost when staff move on. Increased awareness and education about the benefits of CPR training and the emergency chain of survival amongst the community were reported as being essential.

The current PAD Demonstration operates as a trained first responder program rather than a public access defibrillation program.
First aid or emergency training was the key factor in driving the acceptance of the trained first responder programs.
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4.2.2 Government funding for public access defibrillation

Stakeholders reported that government funding gave the establishment of the PAD program a level of support and legitimacy. The government's involvement in the initial stages helped to ease host organisation and general public concerns about liability and litigation from activation of AEDs.

To kick it off with government funding is the best way. The government support demonstrates the value of AEDs to private business … It will get bigger and wider spread and we will get more sources of funding. (Stakeholder)

I don't know what other way it could have been initiated. Government funding initiates the process, provides legislation to protect and reassure and then it can roll on from there. (Stakeholder)

Most stakeholders considered that as the project gains momentum, and more Australians are made aware of the benefits of AEDs, the federal government's role in funding AEDs should diminish. Other developments such as regulation and incentive schemes were identified as important drivers of non-government funded public access defibrillation by some stakeholders.

I doubt that the private market would sustain this program without some sort of incentive. Something like making the defibrillators tax deductible to dull the pain for businesses. (Stakeholder)
Stakeholders noted the need for a shift in expectations from government funding to private enterprise taking responsibility for AEDs, in the context of improved understanding of a standard of care for public liability and workplace safety. Most stated that this shift would not occur without an awareness campaign and stronger public advocacy for AEDs from government.

Government funding was considered appropriate to demonstrate the viability of AEDs in achieving improved patient outcomes for cardiac arrest victims. The ongoing role of federal government was questioned, with a strong view that good corporate governance should require organisations to commit to funding and installing AEDs themselves.