The use of automated external defibrillators:
Some health and safety / legal considerations
The British Heart Foundation (BHF) notes that around 60,000 people in the UK suffer a sudden cardiac arrest (SCA) away from a hospital environment each year. Speed is critical in responding to such an event; the BHF advises that, to give the casualty the best chance of survival, emergency resuscitation should begin with four minutes of initial collapse. The use of an automated external defibrillator (AED) is key in responding to two common types of SCA; as noted by the Resuscitation Council (UK) in their Guidelines 2010 (p 29):
"Electrical defibrillation is well established as the only effective therapy for cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The scientific evidence to support early defibrillation is overwhelming; the delay from collapse to delivery of the first shock is the single most important determinant of survival. If defibrillation is delivered promptly, survival rates as high as 75% have been reported."
Instances of SCA are frequently reported in the national media; in one case, the father of the bride collapsed and tragically died of a heart attack while making his speech at the wedding reception. This devastating event led to a fundraiser by the newlyweds and their guests. Although his family do not believe the equipment would have saved him, the money raised in the gentleman's memory was used to buy a defibrillator for the hotel in the "hope it could help others in the future" (Daily Mail, 26 September 2013).
This highlights the fact that, while not all abnormal heart rhythms will respond to defibrillation, it is best practice to follow the Resuscitation Council (UK)'s advice to keep an AED at hand against the likelihood of someone suffering a type of SCA that is shockable, in order to fulfil their recommendations in this regard:
"The Resuscitation Council (UK) recommends strongly a policy of attempting defibrillation with the minimum of delay in victims of VF / VT cardiac arrest" (Guidelines 2010, p 29)
There are several makes and models of AED on the market and in each case it is important to research the type best suited to a particular environment and the capabilities of the person(s) who will be required to deploy it. Although, as noted by the Resuscitation Council (UK), there is currently no legal requirement for an AED to be provided in specific premises, many organisations have acted on their own initiative to make the equipment available. Once the decision has been made to install an AED, there are certain requirements of the Health and Safety Executive (HSE) which will have to be observed.
AEDs at work: an overview of employer responsibilities
i) First aid / training
In respect of AEDs, current HSE First Aid regulations state: "Where an employer decides to provide a defibrillator in the workplace, those who may need to use it should be trained. Training can provide additional knowledge and skills and may promote greater confidence in the use of a defibrillator" (First aid at work: The Health and Safety (First-Aid) Regulations 1981 (Third Edition) 2013, Regulation 44, p 18). On p 39, the Regulations refer employers to the Resuscitation Council (UK) at www.resus.org.uk for further information on training in the use of automated external defibrillators; the Resuscitation Council (UK) itself notes that training helps "improve the time to shock delivery and correct pad placement". Specifically, in respect of training courses, it cites the ILCOR Consensus on Science and Treatment Recommendations as being "relevant to (its own) AED guidelines", as follows:
"Short video / computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led BLS [Basic Life Support] and AED courses. Such courses should be validated to ensure that they achieve equivalent outcomes to instructor led courses" (Guidelines 2010, p 29)
A typical, instructor-led training course on the use of AEDs, such as the one run by St John Ambulance, takes around 3 hours to deliver, assuming a basic knowledge of first aid (i.e. through prior attendance at an introductory training course for first aiders at work). An understanding of first aid in general is important because an AED is used in conjunction with traditional cardiopulmonary resuscitation (CPR), which is a basic lifesaving technique. Due to the HSE requirement, it is usual for suppliers of defibrillators to include a place on an AED training course as part of the package.
In its publication entitled "The legal status of those who attempt resuscitation" (August 2010, p 8), the Resuscitation Council (UK) sets the wider context of first aid at work, stating: "Under the Health and Safety at Work Act 1974 and the subsequent Health and Safety (First-Aid) Regulations 1981, an employer is under a statutory duty to provide first-aiders in the workplace for the benefit of his employees. These first-aiders must undergo training to an approved standard in a specified list of competencies. As such, an individual who takes on this role as part of his job description could be argued to owe a duty of care to his fellow employees to render first aid."
This duty of care in rendering first aid could potentially involve the use of a defibrillator, in the case of a suspected SCA.
ii) AED maintenance
Apart from ensuring the relevant employees receive appropriate training in the use of AEDs, including on-going refresher courses as recommended by the training body, the employer must also ensure that the device, as all other first aid equipment on the premises, is properly maintained. Failure to maintain an AED unit and its disposable parts (i.e. batteries and pads) can result in it malfunctioning at the critical moment of deployment.
The HSE First Aid Regulations cited earlier identify the responsible person(s) as being either the first aider or an "appointed person" whose role "includes looking after the first-aid equipment and facilities and calling the emergency services when required" (Regulation 7, p 9). The Regulations go on to state that, even though "under the Health and Safety (First Aid) Regulations 1981, you have no legal duty to provide first aid for non-employees... the HSE strongly recommends that you include them in your first-aid provision" (p 12). This again would extend to the question of AED provision and how many might be required, depending on the nature of the premises and how many people outside the workforce visit them.
Guidance to the various issues concerned with AED maintenance can be found at the following link: https://www.safelincs.co.uk/introduction-to-defibrillators/
iii) Liability insurance
It is important to note Regulation 29 of the HSE publication, in respect particularly of first aid provision that is intended to cover both employees and non-employees. This states: "Employers should check their liability insurance covers all the activities of first-aiders".
The issue of insurance cover is also addressed by the Resuscitation Council (UK) in their document "The legal status of those who attempt resuscitation"; the advice of the Council in respect of minimising the risk of personal liability is, along with good practice, to take out adequate indemnity insurance (August 2010, p 14).
The use of AEDs: some legal considerations
Since its launch in 2000, and as noted by the Resuscitation Council (UK) in its above cited document, the government led National Defibrillator Programme has clearly demonstrated that the use of AEDs has been responsible for saving many lives (p 4). The Programme, which is co-ordinated by the British Heart Foundation, has seen the installation of thousands of AEDs nationwide in places where members of the public typically gather in large numbers; for example, railway and bus stations, airport terminal buildings, sports stadia and community centres.
These AEDs have been placed for the purpose of Public Access Defibrillation (PAD) which, as noted by St John Ambulance, "is the term used to describe the use of AEDs by the layperson in a public place". This use by people who often have little or no first aid or medical knowledge, and are first responders simply because they happen to be passing or working nearby, has led to "impressive results (being) reported with survival rates as high as 74% with fast response times often possible when an AED is nearby in a complementary location" (https://www.stjohnsupplies.co.uk/downloads/FAQs_defibrillators.pdf).
Despite the clear advantages of having an AED to hand in cases of SCA, some questions have been raised in respect of the legal status of those who attempt resuscitation. The Resuscitation Council (UK) has sought to address this issue in its document of this name, which was originally published in 2000, revised in August 2010, and is available at https://www.resus.org.uk/pages/legal.pdf.
One concern that has been voiced on behalf of those who might find themselves called upon to use a defibrillator is whether they might be vulnerable to claims for damages should their intervention be unsuccessful. As noted by both St John Ambulance and the Resuscitation Council (UK), there have been no reported cases of anyone in the UK being successfully sued for using an AED on a cardiac arrest casualty.
Furthermore, as noted by the latter: "It is difficult… to see how a rescuer's intervention could leave someone worse off since, in the case of cardiopulmonary arrest, a victim would, without immediate resuscitation, certainly die. Furthermore, if an AED is being used, it will only permit the administration of a defibrillatory shock when its sophisticated electronic algorithms determine that ventricular fibrillation is present and, since patients in this state are clinically dead, it is unlikely that any intervention with this device could make the situation worse" (August 2010, p 9).