Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Janet Bray, Gavin Perkins
Task Force Synthesis Citation
Bray J, Oonyu L, Perkins GD, Smith CM, Vaillancourt C, Olasveengen T on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force. Accessibility of AEDs in locked cabinets Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2024 July 25. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a scoping review of basic life support (Oonyu, 2023 Resuscitation Plus) conducted by the members of the BLS Task Force. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Task Force. These data were taken into account when formulating the Treatment Recommendations.
Scoping Review
Oonyu L, Perkins GD, Smith CM, Vaillancourt C, Olasveengen T, Bray JE on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force. The Impact of Locked Cabinets for Automated External Defibrillators (AEDs) on Cardiac Arrest and AED Outcomes: A Scoping Review. Resuscitation Plus 2024;20:100791.
PICOST
Population: Adults and children in out-of-hospital settings
Concept: The benefits and harms of placing automatic external defibrillators (AEDs) in locked cabinets versus unlocked cabinets
Context: Any locations where an AED is placed with the intention of the AED being publicly accessible for use
Outcomes: Any outcome, including AED outcomes (e.g. AED use, time to AED use, AED vandalism or theft)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), case series, and case reports were eligible for inclusion. Grey literature (Google Scholar search -first 20 pages), letters to the Editor and conference abstracts were also eligible for inclusion.
Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature searched to June 25, 2024.
Search Strategies
Articles for review were obtained by searching Medline, Embase, Cochrane and Google Scholar for all entries from database inception to May 2024 (last searched on May 21, 2024).
Articles are using key terms “Cardiac arrest”, “Automated External Defibrillator", "AED", "Locked cabinet", "Public access defibrillation”; including their MESH terms, and Embase exploded terms.
Inclusion and Exclusion criteria
Studies of any type or design (e.g., experimental, observational, qualitative, conference abstracts, letters to the Editor) that were published with an English abstract and examined the impact of locked AED cabinets were included. Studies examining the accessibility of AEDs in buildings were not included, unless they mentioned locked cabinets. Any outcome, including AED outcomes (e.g. AED use before EMS arrival, time to AED use, AED vandalism or theft) were accepted. Systematic reviews were initially included to review reference lists for missed studies. Authors of conference abstracts were contacted where possible to ascertain whether full results were published. We also contacted the authors of studies that reported rates of theft or vandalism without details of security measures, and these studies were included if any of the AEDs studied were contained in locked cabinets.
Reports were excluded if they reported 1) on the general accessibility of AEDs without rates of theft or vandalism or 2) other outcomes (e.g. the results of surveys of what was considered in the placement of an AED).
Data tables:BLS 2123 Data table AED locked cabinets
Task Force Insights
Please insert your task force insights here. They should comprise 3 sections.
1. Why this topic was reviewed.
- The BLS Task Force prioritized this topic, which has not been reviewed before, to address community concerns about the need for additional security measures to prevent AED theft, vandalism, and misuse.13-15
2. Narrative summary of evidence identified
- We screened 2,096 titles and found 10 relevant studies: 8 observational (4 published as conference abstracts and 2 as letters to the Editor) and 2 simulation studies.1-10
- No study reported on patient outcomes.
- Data were reported on varying numbers of AEDs (range: 39 to 31,938).
- The majority of studies reported low rates of theft and vandalism (<2.0%), including studies with 24-hour access.3-9 The only study comparing unlocked and locked AED cabinets showed low rates of theft in both cabinet types, with the lowest rates seen in locked cabinets (0.3% vs. 0.1%).8
- Two simulation studies showed significantly slower AED retrieval when additional security measures were used, including locked cabinets.1,2
- One survey of first responders reported half (24/45) were injured, most (62.5%) injuries occurred by using body parts to break the glass necessary to access a key to unlock the AED.10
3. Narrative Reporting of the task force discussions
- Rapid defibrillation is critical to improving patient outcomes, and patients who receive defibrillation from bystanders have the greatest chance of survival.16
- AEDs cabinets are typically locked with a code or key. Additional security may also be present (e.g. locked in a room in a locked cabinet).
- While acknowledging that most of the data identified has not undergone peer review and may be publication bias, reported rates of AED theft and vandalism were low across all studies, and thefts occurred in both locked and unlocked cabinets.4,8 It was not reported if AEDs reported as stolen could potentially have been used in an emergency and not returned.
- AED mapping studies show additional security measures, such as locking AEDs within buildings, reduces accessibility17 and simulation studies show when combined with locked cabinets increases the time to access the device.1,2
- One study suggests issues with rescuer’s ability to follow the instructions on cabinets to retrieve keys to unlock cabinets.
- The cost to replace stolen or vandalized AEDs may be an issue in low-resource settings (e.g. community groups with limited funding).
- Some regions have opted to lock their public access defibrillators with a code that can be retrieved by calling the emergency number to encourage rescuers to call an ambulance as a first action.
- Tracking devices may be useful to retrieve missing or stolen AEDs.
- AED cabinet design should not result in harm to rescuers.
- We agree with the 2022 ILCOR Scientific Statement which, focuses on optimizing public access defibrillation, and advises against using locked cabinets. If locked cabinets are used, instructions for unlocking them need to be clear and ensure no delays in access.11,12
4. Good practice statements
We advise against using locked cabinets (Good Practice Statement).
If locked cabinets are used, instructions for unlocking them must be clear and ensure minimal delays in access (Good Practice Statement).
Emergency Medical Services should devise strategies to return public access defibrillators when used (Good Practice Statement).
Knowledge Gaps
Peer-reviewed research and human studies are needed on this topic, particularly studies focusing on real-life retrieval and the impact of security strategies on delivery times and patient outcomes.
EtD: BLS 2123 AED Accessibility locked cabinets ETD
References
1. Uhm TH and Kim JH. Factors affecting delivery time of public access defibrillator in apartment houses. Indian Journal of Public Health Research and Development. 2018;9(9):534-40.
2. Telec W, Baszko A, Dabrowski M, Dabrowska A, Sip M, Puslecki M, Klosiewicz T, Potyrala P, Jurczyk W, Maciejewski A, Zalewski R, Witt M, Ladny JR and Szarpak L. Automated external defibrillator use in public places: a study of acquisition time. Kardiologia polska. 2018;76:181-5.
3. Salerno J, Willson C, Weiss L and Salcido D. Myth of the stolen AED. Resuscitation. 2019;140:1.
4. Peberdy MA, Ottingham LV, Groh WJ, Hedges J, Terndrup TE, Pirrallo RG, Mann NC and Sehra R. Adverse events associated with lay emergency response programs: the public access defibrillation trial experience. Resuscitation. 2006;70:59-65.
5. Page G and Bray J. Unlocking the key to increasing survival from out-of-hospital cardiac arrest - 24/7 accessible AEDs. Resuscitation. 2024:110227.
6. Ludgate MB, Kern KB, Bobrow BJ and Ewy GA. Donating automated external defibrillators may not be enough. Circulation Conference: American Heart Association. 2012;126.
7. Benvenuti C, Burkart R and Mauri R. Public defibrillators and vandalism: Myth or reality? Resuscitation. 2013;1):S69.
8. Cheema K, O'Connell D, Herz N, Adebayo A, Thorpe J, Benson-Clarke A and Perkins G. The influence of locked automated external defibrillators (AEDs) cabinets on the rates of vandalism and theft. Resuscitation. 2022;175(Supplement 1):S80.
9. Brugada R, Morales A, Ramos R, Heredia J, De Morales ER and Batlle P. Girona, cardio-protected territory. Resuscitation. 2014;1):S57.
10. NG JSY, HO, R.J.S., YU, J. ., NG, Y.Y. Factors Influencing Success and Safety of AED Retrieval in out of Hospital Cardiac Arrests in Singapore. The Korean Journal of Emergency Medical Services 2022;26:97-111.
11. Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, Parr M, Morrison LJ, Wang T-L, Koster RW and Ong MEH. Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation. Resuscitation. 2022;172:204-28.
12. Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, Parr M, Morrison LJ, Wang TL, Koster RW, Ong MEH and International Liaison Committee on R. Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation. Resuscitation. 2022;172:204-28.
13. O'Callaghan PA, Swampillai J and Stiles MK. Availability of automated external defibrillators in Hamilton, New Zealand. N Z Med J. 2019;132:75-82.
14. Lac D, Wolters MK, Leung KHB, MacInnes L and Clegg GR. Factors affecting public access defibrillator placement decisions in the United Kingdom: A survey study. Resusc Plus. 2023;13:100348.
15. Fortington LV, Bekker S and Finch CF. Integrating and maintaining automated external defibrillators and emergency planning in community sport settings: a qualitative case study. Emerg Med J. 2020;37:617-22.
16. Nehme Z, Andrew E, Bernard S, Haskins B and Smith K. Trends in survival from out-of-hospital cardiac arrests defibrillated by paramedics, first responders and bystanders. Resuscitation. 2019;143:85-91.
17. Ball S, Morgan A, Simmonds S, Bray J, Bailey P and Finn J. Strategic placement of automated external defibrillators (AEDs) for cardiac arrests in public locations and private residences. Resusc Plus. 2022;10:100237.