Research Letter
Health Care Policy and Law
January 2, 2024
Automated External Defibrillator Use After Out-of-Hospital Cardiac Arrest at Recreational Facilities
Ahmed A. Kolkailah, Paul S. Chan, Qiang Li, et al
JAMA Intern Med. Published online January 2, 2024. doi:10.1001/jamainternmed.2023.7248
Out-of-hospital cardiac arrest (OHCA) during exercise is often due to a ventricular arrhythmia for which prompt defibrillation from an automated external defibrillator (AED) can be lifesaving.1 Some US states have enacted laws requiring athletic facilities to have an AED on-site.2,3 However, contemporary rates of bystander AED application in states that have enacted such laws remain unknown. This cohort study used the Cardiac Arrest Registry to Enhance Survival (CARES)4 to examine bystander AED application and survival outcomes for OHCA at recreational facilities in states with and without AED legislation.
Using CARES data from January 1, 2013, to December 31, 2021, we identified 10 008 adults (age ≥18 years) with nontraumatic OHCA at recreational facilities. We excluded 669 cases of OHCA witnessed by 911 responders, 39 cases in 1 state that passed AED legislation in 2020, and 10 cases in 3 states with fewer than 5 OHCA cases at recreational facilities. Outcomes were bystander AED application, survival to admission, and survival to discharge. We report demographics, cardiac arrest characteristics, and study outcomes for OHCA at recreational facilities in law and nonlaw states. Given the cross-sectional nature of our analysis and lack of OHCA data before AED laws were passed, we did not directly compare AED rates or survival between law and nonlaw states. Analysis was performed using SAS, version 9.4. This study was approved by the institutional review board at The University of Texas Southwestern Medical Center, which waived the requirement for informed consent because deidentified data were used. This study followed the STROBEreporting guideline.
A total of 4145 OHCA cases at recreational facilities in 13 AED law states and 5145 cases in 27 nonlaw states were included. The initial rhythm was shockable in 4342 cases (46.8%), 6275 cases (67.6%) were witnessed, and bystander cardiopulmonary resuscitation was performed in 5693 cases (61.3%) (Table).
Among law states, the median rate of bystander AED application was 19.0% and varied markedly across states (IQR, 15.1%-22.0%; range, 8.6%-28.8%) (Figure). Median survival to admission was 44.5% (IQR, 39.4%-56.9%; range, 36.0%-58.6%), and median survival to discharge was 31.0% (IQR, 25.2%-32.8%; range, 18.9%-42.9%). Among nonlaw states, the median rate of bystander AED application was 18.2% (IQR, 13.9%-25.0%; range, 7.4%-50.0%) (Figure). Median survival to admission was 45.0% (IQR, 38.4%-52.1%; range, 33.3%-70.0%), and median survival to discharge was 28.4% (IQR, 25.9%-37.5%; range, 15.8%-50.0%).
Prompt application of an AED is a critical link in the chain of survival.5 Many US states have passed legislation requiring AEDs at athletic facilities as part of granting an operating license. Despite these well-intended efforts, 19.0% of patients had an AED applied by a bystander in states requiring AEDs at athletic facilities, and this rate was numerically similar in law and nonlaw states even though shockable rhythms comprised 46.8% of all OHCAs. Among law states, bystander AED application varied but was still only 28.8%% in the best performing state. Our findings highlight that legislative efforts alone may not be sufficient to improve bystander AED use; additional efforts, such as geolocation of available AEDs, ensuring procurement, appropriate signage, dispatcher-assisted guidance, and continued education of facilities staff and the lay public, may be necessary.6
Although CARES is the largest OHCA database in the US, our findings may not generalize to nonparticipating sites. In addition to athletic facilities, recreational facilities in CARES can include campsites, beaches, public parks, and trails. The availability of AEDs on-site in law states cannot be confirmed as this information is not collected in CARES. All states had passed AED laws before our study period, which precluded the use of methods to directly determine a change in bystander AED use after passage of laws.
This study found that rates of bystander AED use in OHCA at recreational facilities remained low through 2021, even in states legislating on-site availability. Additional efforts are needed to overcome barriers for public access defibrillation.
