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 applicable)
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: (none applicable)
CoSTR Citation
Chung C, Lim SH, Avis S, Brooks S, Castren M, Considine J, Duff J, Grief R, Kudenchuck P, Mancini MB, Nishiyama C, Perkins GD, Ristagno G, Semeraro F, Smith C, Smyth M, Olasveengen TM, Morley P - on behalf of the International Liaison Committee on Resuscitation Basic and Education Implementation and Teams Task Forces. Feedback for CPR quality in Adults and Children Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Feb 10th. Available from: http://ilcor.org
Methodological Preamble
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support conducted by Sung Phil Chung and Swee Han Lim with involvement of clinical content experts. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force and Education Implementation and Teams Task Force. These data were taken into account when formulating the Treatment Recommendations.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Among adults and children who are in out-of-hospital cardiac arrest
Intervention: implementation of a public access AED program
Comparators: traditional EMS response
Outcomes: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC), bystander CPR rates, time to first compressions, time to first shock, and CPR quality was ranked as important outcomes.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
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 search updated to Oct, 2019.
In most cases bias was assessed per comparison rather than per outcome, since there were no meaningful differences in bias across outcomes.
Consensus on Science
Systematic reviews on the effects of public access defibrillation (PAD) on OHCA survival have been published previously.{Holmberg 2017 77, Baekgaard 2017 954} This review is focused on comparing outcomes in systems with public access AED programs with systems with traditional EMS response, and included 1 RCT and 30 observational studies. Public access defibrillation is defined as defibrillation with onsite AED by a layperson in the OHCA setting. The PAD group included only patients defibrillated by a lay person using an onsite AED. The CPR only group included all patients not receiving PAD – meaning not treated with an onsite AED by a lay person, and included patients defibrillated by professional first responders such as police or firefighters.
For the critical outcome of survival to 1 year with favorable neurological outcome, we identified low-certainty evidence (downgraded for risk of bias) from one observational trial {Gianotto-Oliveira 2015 e002185} enrolling 62 patients showing improvement (43% vs 0%, p=0.02) after a public-access defibrillation program in a subway system.
For the critical outcome of survival to 30 days with favorable neurological outcome, we identified low-certainty evidence (downgraded for risk of bias and inconsistency) from 7 observational studies {Nakahara 2015 247, Kitamura 2016 1649, Fukuda 2017 1, Takeuchi 2018 217, Kiguchi 2019 1682, Tay 2020 220, Matsui 2019 150} enrolling 43,116 patients demonstrating improved survival with public-access defibrillation program (OR, 6.60; 95% CI, 3.54–12.28).
For the critical outcome of survival to hospital discharge with favorable neurological outcome, we identified low-certainty evidence (downgraded for risk of bias) from 8 observational studies. The studies {Capucci 2002 1065, Kuisma 2003 149, Berdowski 2011 2225, Gianotto-Oliveira 2015 e002185, Fordyce 2017 1226, Andersen 2018 72, Aschieri 2018 1344, Pollack 2018 2104} included 11,837 patients demonstrating improved survival with public-access defibrillation program (OR, 2.89; 95% CI, 1.79–4.66).
For the critical outcome of survival to 30 days, we identified low-certainty evidence (downgraded for risk of bias) from 8 observational studies {Ringh 2015 1, Kitamura 2016 1649, Hansen 2017 507, Claesson 2017 1043, Kiguchi 2019 1682, Fukuda 2017 1, Dicker 2018 662, Tay 2020 220} enrolling 85,589 patients demonstrating improved outcome with public-access defibrillation program (OR, 3.66; 95% CI, 2.63–5.11).
For the critical outcome of survival to hospital discharge, we identified moderate certainty evidence (downgraded for risk of bias) from 1 RCT {Hallstrom 2004 637} enrolling 235 OHCA showing improved survival with PAD compared to no PAD (RR, 2.0; 95% CI, 1.07–3.77) and low-certainty evidence (downgraded for risk of bias) from 16 observational studies enrolling 40,243 patients showing improved survival associated with public -access defibrillation programs (OR, 3.24; 95% CI, 2.13–4.92). {Capucci 2002 1065, Kuisma 2003 149, Culley 2004 1859, Feischhackl 2008 195, Colquhoun 2008 275, Weisfeldt 2010 1713, Berdowski 2011 2225, Edwards 2015 e000281, Capucci 2016 192, Garcia 2017 e63, Fordyce 2017 1226, Karam 2017 16, Andersen 2018 72, Nas 2018 600, Pollack 2018 2104, Nehme 2019 85}
For the important outcome survival to admission, we identified low-certainty evidence (downgraded for risk of bias) from 4 observational studies {Kim 2014 63, Capucci 2016 192, Garcia 2017 e63, Pollack 2018 2104} enrolling 7,641 patients demonstrating improved survival with public-access defibrillation program (OR, 1.79; 95% CI, 1.49–2.14).
For the important outcome return of spontaneous circulation, we identified low-certainty evidence (downgraded for risk of bias) from 13 observational studies {Colquhoun 2008 275, Gianotto-Oliveira 2015 e002185, Ringh 2015 1, Kitamura 2016 1649, Hansen 2017 507, Fukuda 2017 1, Garcia 2017 e63, Andersen 2018 72, Dicker 2018 662, Nas 2018 600, Pollack 2018 2104, Kiguchi 2019 1682, Tay 2020 220} enrolling 95,354 patients demonstrating improved ROSC rate with public -access defibrillation program (OR 2.45; 95% CI, 1.88–3.18).
Treatment Recommendations
We recommend the implementation of public-access defibrillation programs for patients with OHCAs. (Strong recommendation, low-certainty evidence)
Justification and Evidence to Decision Framework Highlights
In making this recommendation, we place a high value on the potential life-saving capability of an AED for a shockable rhythm as well keeping with the previous treatment recommendation when there is no compelling data suggesting the need to change. We recognize there are barriers to the implementation of PAD programs. The ILCOR Scientific Statement on Public Access Defibrillation addresses key interventions (early detection, optimizing availability, signage, novel delivery methods, public awareness, device registration, mobile apps for AED retrieval and personal access defibrillation) which should be considered as part of all public access defibrillation programs {Brooks 2020 TBC}.
Cost-effectiveness of PAD program may be various according to country. A recent review found cost-effectiveness ratios between 37,200~1,152,400 USD/QALY {Holmberg 2017 77}. Another recent cost-effectiveness analysis study {Andersen 2019 250} from United States concluded public access AEDs are a cost-effective public health intervention.
Among 31 included studies, there was only one randomized controlled trial, which showed improved survival to discharge in CPR plus AED group compared with CPR only group. Observational studies were mostly retrospective analysis from large registry data and generally showed improved survival outcomes associated with public access defibrillation. However, there were some inconsistencies among the observational as some were unable to show any significant differences in outcomes {Kuisma 2003 149, Gianotto-Oliveira 2015 e002185, Nas 2018 600, Tay 2020 220}. There was also important heterogeneity among studies in the meta-analysis. The location of cardiac arrest was various including airports {Garcia 2017 e63}, subway {Gianotto-Oliveira 2015 e002185}, and sports facilities {Aschieri 2018 1344}). The population varied with one study including only pediatric patients {Fukuda 2017 1, Matsui 2019 150}. The control group also varied among studies as some patients in control groups received first responder defibrillation whereas others did not. Some studies were before and after studies where historic controls {Fleischhackl 2008 195, Nas 2018 600} included both periods prior to PAD implementation {Tay 2020 220} or the initial period of implementation {Gianotto-Oliveira 2015 e002185}. Despite such heterogeneity, all patients in those studies had OHCA and most studies showed implementation of PAD improved survival.
Knowledge Gaps
Current knowledge gaps include but are not limited to:
• Optimal placement/location of AEDs?
• Optimal role of emergency medical dispatchers in identifying nearest AED and alerting callers to their location?
• How AEDs could be most effectively integrated into citizen responder programs?
Attachments
Evidence-to-Decision Table: BLS-347-Public-access-AED-program
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