The general public’s ability to operate automated external defibrillator: A controlled simulation study

doi:10.5847/wjem.j.1920-8642.2020.04.006

Abstract

Abstract:

BACKGROUND: Automated external defibrillators (AEDs) enable laypeople to provide early defibrillations to patients undergoing cardiac arrest, but scant information is available on the general public’s ability to use AEDs. This study assessed the ability of laypeople to operate AEDs, the effect of a 15-minute training, and whether skills differed by age.

METHODS: From May 1 to December 31, 2018, a prospective simulation study was conducted with 94 laypeople aged 18-65 years (32 aged 18-24 years, 34 aged 25-54 years, and 28 aged 55-65 years) with no prior AED training. The participants’ AED skills were assessed individually pre-training, post-training, and at a three-month follow-up using a simulated cardiac arrest scenario. The critical actions and time intervals were evaluated during the AED operating process.

RESULTS: Only 14 (14.9%) participants (eight aged 18-24 years, four aged 25-54 years, and two aged 55-65 years) successfully delivered defibrillations before training. AED operation errors were more likely to occur among the participants aged 55-65 years than among other age groups. After training, the proportion of successful defibrillations increased significantly (18-24 years old: 25.0% vs. 71.9%, P<0.01; 25-54 years old: 11.8% vs. 70.6%, P<0.01; 55-65 years old: 7.1% vs. 67.9%, P<0.01). After three months, 26.1% of the participants aged 55-65 years successfully delivered defibrillations, which was significantly lower than that of participants aged 18-24 years (54.8%) and 25-54 years (64.3%) (P=0.02). There were no differences in time measures among three age groups in each test.

CONCLUSIONS: The majority of untrained laypeople cannot effectively operate AEDs. More frequent training and refresher courses are crucial to improve AED skills.

Key words: Automated external defibrillator, Cardiac arrest, General public, Training, Simulation

Xue-jie Dong, Lin Zhang, Yue-lin Yu, Shu-xiao Shi, Xiao-chen Yang, Xiao-qian Zhang, Shuang Tian, Helge Myklebust, Guo-hong Li, Zhi-jie Zheng. The general public’s ability to operate automated external defibrillator: A controlled simulation study[J]. World Journal of Emergency Medicine, 2020, 11(4): 238-245.

Figures/Tables 6

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Table 1

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Table 3

References 38

1	Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S414-35. doi: 10.1161/CIR.0000000000000259 pmid: 26472993
2	Perkins GD, Handley AJ, Koster RW, Castren M, Smyth MA, Olasveengen T, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult Basic Life Support and Automated External Defibrillation. Resuscitation. 2015; 95:81-99. doi: 10.1016/j.resuscitation.2015.07.015 pmid: 26477420
3	Baekgaard JS, Viereck S, Moller TP, Ersboll AK, Lippert F, Folke F. The effects of public access defibrillation on survival after out-of-hospital cardiac arrest: a systematic review of observational studies. Circulation. 2017; 136(10):954-65. doi: 10.1161/CIRCULATIONAHA.117.029067 pmid: 28687709
4	Holmberg MJ, Vognsen M, Andersen MS, Donnino MW, Andersen LW. Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2017; 120:77-87. doi: 10.1016/j.resuscitation.2017.09.003 pmid: 28888810
5	Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010; 3(1):63-81. doi: 10.1161/CIRCOUTCOMES.109.889576 pmid: 20123673
6	Kiyohara K, Kitamura T, Sakai T, Nishiyama C, Nishiuchi T, Hayashi Y, et al. Public-access AED pad application and outcomes for out-of-hospital cardiac arrests in Osaka, Japan. Resuscitation. 2016; 106:70-5. doi: 10.1016/j.resuscitation.2016.06.025 pmid: 27373223
7	Zijlstra JA, Bekkers LE, Hulleman M, Beesems SG, Koster RW. Automated external defibrillator and operator performance in out-of-hospital cardiac arrest. Resuscitation. 2017; 118:140-6. doi: 10.1016/j.resuscitation.2017.05.017 pmid: 28526495
8	Bodtker H, Rosendahl D. Automated external defibrillators and defibrillation electrodes from major manufactures depict placement of the left apical defibrillation electrode poorly! Resuscitation. 2018; 125:e11-e2. doi: 10.1016/j.resuscitation.2018.01.046 pmid: 29408601
9	Agerskov M, Nielsen AM, Hansen CM, Hansen MB, Lippert FK, Wissenberg M, et al. Public access defibrillation: great benefit and potential but infrequently used. Resuscitation. 2015; 96:53-8. doi: 10.1016/j.resuscitation.2015.07.021 pmid: 26234893
10	Olasveengen TM, de Caen AR, Mancini ME, Maconochie IK, Aickin R, Atkins DL, et al. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations Summary. Resuscitation. 2017; 121:201-14. doi: 10.1016/j.resuscitation.2017.10.021 pmid: 29128145
11	Yeung J, Okamoto D, Soar J, Perkins GD. AED training and its impact on skill acquisition, retention and performance—a systematic review of alternative training methods. Resuscitation. 2011; 82(6):657-64. doi: 10.1016/j.resuscitation.2011.02.035
12	Gundry JW, Comess KA, DeRook FA, Jorgenson D, Bardy GH, . Comparison of naive sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation. 1999; 100(16):1703-7. doi: 10.1161/01.cir.100.16.1703 pmid: 10525489
13	Beckers S, Fries M, Bickenbach J, Derwall M, Kuhlen R, Rossaint R. Minimal instructions improve the performance of laypersons in the use of semiautomatic and automatic external defibrillators. Crit Care. 2005; 9(2):R110-6. doi: 10.1186/cc3033 pmid: 15774042
14	Beckers SK, Fries M, Bickenbach J, Skorning MH, Derwall M, Kuhlen R, et al. Retention of skills in medical students following minimal theoretical instructions on semi and fully automated external defibrillators. Resuscitation. 2007; 72(3):444-50. doi: 10.1016/j.resuscitation.2006.08.001 pmid: 17188417
15	Mattei LC, McKay U, Lepper MW, Soar J. Do nurses and physiotherapists require training to use an automated external defibrillator? Resuscitation. 2002; 53(3):277-80. doi: 10.1016/s0300-9572(02)00023-0 pmid: 12062843
16	Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA. 2013; 310(13):1377-84. doi: 10.1001/jama.2013.278483 pmid: 24084923
17	Global Resuscitation Alliance. The WeCan CPR Training Program in China. Available at https://www.globalresuscitationalliance.org/wp-content/uploads/2019/12/China_Community_Training.pdf. July 20, 2020 update.
18	Soar J, Nolan JP, Bottiger BW, Perkins GD, Lott C, Carli P, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult Advanced Life Support. Resuscitation. 2015; 95:100-47. doi: 10.1016/j.resuscitation.2015.07.016 pmid: 26477701
19	Smith CM, Lim Choi Keung SN, Khan MO, Arvanitis TN, Fothergill R, Hartley-Sharpe C, et al. Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review. Eur Heart J Qual Care Clin Outcomes. 2017; 3(4):264-73. doi: 10.1093/ehjqcco/qcx023 pmid: 29044399
20	Smith CM, Perkins GD. Improving bystander defibrillation for out-of-hospital cardiac arrest: capability, opportunity and motivation. Resuscitation. 2018; 124:A15-6. doi: 10.1016/j.resuscitation.2018.01.006 pmid: 29337173
21	Zhang L, Li B, Zhao X, Zhang Y, Deng Y, Zhao A, et al. Public access of automated external defibrillators in a metropolitan city of China. Resuscitation. 2019; 140:120-6. doi: 10.1016/j.resuscitation.2019.05.015 pmid: 31129230
22	Basanta Camiño S, Navarro Patón R, Freire Tellado M, Barcala Furelos R, Pavón Prieto MP, Fernández López M, et al. Assessment of knowledge and skills in using an automated external defibrillator (AED) by university students. A quasi-experimental study. Med Intensiva. 2017; 41(5):270-6. doi: 10.1016/j.medin.2016.07.008 pmid: 27773493
23	Brooks B, Chan S, Lander P, Adamson R, Hodgetts GA, Deakin CD. Public knowledge and confidence in the use of public access defibrillation. Heart. 2015; 101(12):967-71. doi: 10.1136/heartjnl-2015-307624 pmid: 25926599
24	Esibov A, Chapman FW, Melnick SB, Sullivan JL, Walcott GP. Minor variations in electrode pad placement impact defibrillation success. Prehosp Emerg Care. 2016; 20(2):292-8. doi: 10.3109/10903127.2015.1076095 pmid: 26383036
25	Staerk M, Bodtker H, Lauridsen KG, Lofgren B. Automated external defibrillation training on the left or the right side—a randomized simulation study. Open Access Emerg Med. 2017; 9:73-9. doi: 10.2147/OAEM.S140220 pmid: 29066936
26	Bodtker H, Rosendahl D. Correct AED electrode placement is rarely achieved by laypersons when attaching AED electrodes to a human thorax. Resuscitation. 2018; 127:e12-3. doi: 10.1016/j.resuscitation.2018.04.002 pmid: 29627397
27	Nurmi J, Castren M. Layperson positioning of defibrillation electrodes guided by pictorial instructions. Resuscitation. 2005; 64(2):177-80. doi: 10.1016/j.resuscitation.2004.08.014 pmid: 15680526
28	Foster AG, Deakin CD. Accuracy of instructional diagrams for automated external defibrillator pad positioning. Resuscitation. 2019; 139:282-8. doi: 10.1016/j.resuscitation.2019.04.034 pmid: 31063839
29	Mosesso VN Jr, Shapiro AH, Stein K, Burkett K, Wang H. Effects of AED device features on performance by untrained laypersons. Resuscitation. 2009; 80(11):1285-9. doi: 10.1016/j.resuscitation.2009.07.016
30	Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation. Resuscitation. 2015; 95:288-301. doi: 10.1016/j.resuscitation.2015.07.032 pmid: 26477418
31	Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman JM, et al. Part 14: Education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 suppl 2):S561-73. doi: 10.1161/CIR.0000000000000268 pmid: 26473002
32	Meischke HW, Rea T, Eisenberg MS, Schaeffer SM, Kudenchuk P. Training seniors in the operation of an automated external defibrillator: a randomized trial comparing two training methods. Ann Emerg Med. 2001; 38(3):216-22. doi: 10.1067/mem.2001.115621
33	Mitchell KB, Gugerty L, Muth E. Effects of brief training on use of automated external defibrillators by people without medical expertise. Hum Factors. 2008; 50(2):301-10. doi: 10.1518/001872008X250746 pmid: 18516840
34	Christenson J, Nafziger S, Compton S, Vijayaraghavan K, Slater B, Ledingham R, et al. The effect of time on CPR and automated external defibrillator skills in the public access defibrillation trial. Resuscitation. 2007; 74(1):52-62. doi: 10.1016/j.resuscitation.2006.11.005 pmid: 17303309
35	Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: a randomised controlled trial. Resuscitation. 2006; 71(2):237-47. doi: 10.1016/j.resuscitation.2006.04.005 pmid: 17010497
36	Mabrouk Z, Helmert JR, Müller MP. Evaluation of a usability optimized AED design. Resuscitation. 2018; 130:e57-8.
37	Maes F, Marchandise S, Boileau L, Le Polain de Waroux JB, Scavee C. Evaluation of a new semiautomated external defibrillator technology: a live case video recording study. Emerg Med J. 2015; 32(6):481-5. doi: 10.1136/emermed-2013-202962 pmid: 25082717
38	Carballo-Fazanes A, Jorge-Soto C, Abelairas-Gómez C, Bello-Rodríguez J, Fernández-Méndez F, Rodríguez-Núñez A. Could mobile apps improve laypeople AED use? Resuscitation. 2019; 140:159-60. doi: 10.1016/j.resuscitation.2019.05.029 pmid: 31153946

Critical actions	Pre-training (n=94)	Post-training (n=94)	Three-month follow-up^a (n=82)	P-value^b (pre-training vs. post-training)	P-value^b (post-training vs. follow-up)
Successful defibrillations	14 (14.9)	66 (70.2)	41 (50.0)	<0.001	0.01
Turning on the AED	94 (100.0)	94 (100.0)	82 (100.0)	-	-
Baring the chest	59 (62.8)	94 (100.0)	75 (91.4)	<0.001	0.01
Placing the electrodes	66 (70.2)	94 (100.0)	78 (95.1)	<0.001	0.05
Correct electrode placement	17 (18.1)	72 (76.6)	44 (53.7)	<0.001	<0.01
Attaching the connector	94 (100.0)	94 (100.0)	82 (100.0)	-	-
Clear while AED analyzes the rhythm	72 (76.6)	86 (91.5)	76 (92.7)	0.005	0.79
Clear while AED delivers the shock	87 (92.6)	93 (98.9)	79 (96.3)	0.070	0.34
Pressing the shock button	94 (100.0)	94 (100.0)	82 (100.0)	-	-
Resuming CPR after shock	9 (9.6)	82 (87.2)	46 (56.1)	<0.001	<0.01

Critical actions	Pre-training				Post-training				Three-month follow-up^a
Critical actions	18-24 (n=32)	25-54 (n=34)	55-65 (n=28)	P-value^b	18-24 (n=32)	25-54 (n=34)	55-65 (n=28)	P-value^b	18-24 (n=31)	25-54 (n=28)	55-65 (n=23)	P-value^b
Successful defibrillations	8 (25.0)	4 (11.8)	2 (7.1)	0.15	23 (71.9)	24 (70.6)	19 (67.9)	0.96	17 (54.8)	18 (64.3)	6 (26.1)	0.02
Turning on the AED	32 (100.0)	34 (100.0)	28 (100.0)	-	32 (100.0)	34 (100.0)	28 (100.0)	-	31 (100.0)	28 (100.0)	23 (100.0)	-
Baring the chest	27 (84.4)	25 (73.5)	7 (25.0)	<0.01	32 (100.0)	34 (100.0)	28 (100.0)	-	30 (96.8)	26 (92.9)	19 (82.6)	0.37
Placing the electrodes	31 (96.9)	26 (76.5)	9 (32.1)	<0.01	32 (100.0)	34 (100.0)	28 (100.0)	-	31 (100.0)	27 (96.4)	20 (87.0)	0.06
Correct electrode placement	10 (31.3)	4 (11.8)	3 (10.7)	0.06	27 (84.4)	24 (70.6)	21 (75.0)	0.41	17 (54.8)	18 (64.3)	6 (26.1)	0.02
Attaching the connectors	32 (100.0)	34 (100.0)	28 (100.0)	-	32 (100.0)	34 (100.0)	28 (100.0)	-	31 (100.0)	28 (100.0)	23 (100.0)	-
Clear while AED analyzes the rhythm	27 (84.4)	27 (79.4)	18 (64.3)	0.17	27 (84.4)	33 (97.1)	26 (92.9)	0.18	28 (90.3)	28 (100.0)	20 (87.0)	0.17
Clear while AED delivers the shock	31 (96.9)	34 (100.0)	22 (78.6)	0.01	31 (96.9)	34 (100.0)	28 (100.0)	0.38	28 (90.3)	28 (100.0)	23 (100.0)	0.11
Pressing the shock button	32 (100.0)	34 (100.0)	28 (100.0)	-	32 (100.0)	34 (100.0)	28 (100.0)	-	31 (100.0)	28 (100.0)	23 (100.0)	-
Resuming CPR after shock	3 (9.4)	4 (11.8)	2 (7.1)	0.91	26 (81.3)	30 (88.2)	26 (92.9)	0.43	22 (71.0)	20 (71.4)	4 (17.4)	<0.01

Time intervals	Pre-training				Post-training				Three-month follow-up
Time intervals	18-24 (n=8)	25-54 (n=4)	55-65 (n=2)^b	P-value^c	18-24 (n=23)	25-54 (n=24)	55-65 (n=19)	P-value^c	18-24 (n=17)	25-54 (n=18)	55-65 (n=6)	P-value^c
Time for power on	79 (20-155)	28 (13-92)	18, 39	0.06	26 (11-52)	17 (10-43)	20 (12-56)	0.38	31 (22-53)	29 (17-52)	32 (9-41)	0.07
Time to start baring chest	42 (31-65)	44 (41-51)	1, 19	0.55	12 (4-17)	16 (6-25)	14 (1-22)	0.48	4 (1-11)	9 (3-24)	15 (10-31)	0.14
Time for baring the chest	12 (8-15)	8 (7-10)	4, 5	0.08	7 (6-8)	7 (6-9)	6 (6-7)	0.54	6 (6-10)	8 (6-10)	8 (7-8)	0.78
Time for placing the electrodes	24 (18-36)	23 (17-45)	14, 17	0.03	16 (13-23)	17 (11-23)	16 (13-19)	0.60	20 (18-22)	19 (14-23)	16 (13-18)	0.02
Time for inserting the plug	8 (4-11)	6 (3-8)	5, 7	0.94	4 (2-4)	3 (2-6)	3 (3-5)	0.10	4 (3-7)	3 (2-5)	6 (4-6)	0.41
Time for AED indicating a shock	113 (99-177)	105 (100-125)	81, 88	0.09	73 (62-83)	79 (66-86)	76 (72-82)	0.96	78 (73-87)	74 (63-90)	86 (72-103)	0.33
Time for response to shock instruction	3 (3-4)	5 (3-5)	4, 4	0.31	2 (1-3)	3 (2-4)	3 (2-4)	0.01	4 (2-4)	4 (2-5)	5 (3-6)	0.56
Time for shock	117 (102-181)	110 (105-128)	85, 92	0.09	76 (63-86)	82 (69-91)	79 (77-86)	0.90	80 (76-90)	78 (68-95)	93 (75-106)	0.38
Time for resuming CPR after shock	6 (1-12)	15 (12-15)	16, 16	0.23	9 (6-10)	9 (8-10)	10 (9-12)	0.01	12.5 (6-20)	9 (8-11)	9 (9-9)	0.16

[1]	Janett Kreutziger, Philip Puchner, Stefan Schmid, Wolfgang Mayer, Harald Prossliner, Wolfgang Lederer. Accuracy of training blood volume quantification using a visual estimation tool [J]. World Journal of Emergency Medicine, 2021, 12(3): 174-178.
[2]	Alexei Birkun, Fatima Trunkwala, Adhish Gautam, Miriam Okoroanyanwu, Adesokan Oyewumi. Availability of basic life support courses for the general populations in India, Nigeria and the United Kingdom: An internet-based analysis [J]. World Journal of Emergency Medicine, 2020, 11(3): 133-139.
[3]	Avir Mitra, Asaf Gave, Kelsey Coolahan, Thomas Nguyen. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting [J]. World Journal of Emergency Medicine, 2019, 10(4): 210-214.
[4]	Ye-cheng Liu, Yan-meng Qi, Hui Zhang, Joseph Walline, Hua-dong Zhu. A survey of ventilation strategies during cardiopulmonary resuscitation [J]. World Journal of Emergency Medicine, 2019, 10(4): 222-227.
[5]	Alexander S. Kwon, Shadi Lahham, John C. Fox. Can an 8^th grade student learn point of care ultrasound? [J]. World Journal of Emergency Medicine, 2019, 10(2): 109-113.
[6]	Alexei Birkun, Yekaterina Kosova. Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea [J]. World Journal of Emergency Medicine, 2018, 9(4): 237-248.
[7]	Michael D.T. Yue, David W. Spivey, Daniel B. Gingold, Douglas G. Sward. The effect of wilderness and medical training on injury and altitude preparedness among backcountry hikers in Rocky Mountain National Park [J]. World Journal of Emergency Medicine, 2018, 9(3): 172-177.
[8]	Alexei Birkun, Maksim Glotov, Herman Franklin Ndjamen, Esther Alaiye, Temidara Adeleke, Sergey Samarin. Pre-recorded instructional audio vs. dispatchers’ conversational assistance in telephone cardiopulmonary resuscitation: A randomized controlled simulation study [J]. World Journal of Emergency Medicine, 2018, 9(3): 165-171.
[9]	Ahmad Aalam, Mark Zocchi, Khalid Alyami, Abdullah Shalabi, Abdullah Bakhsh, Asaad Alsufyani, Abdulrahman Sabbagh, Mohammed Alshahrani, Jesse M. Pines. Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia [J]. World Journal of Emergency Medicine, 2018, 9(1): 5-13.
[10]	Alexei Birkun, Maksim Glotov. Education in cardiopulmonary resuscitation in Russia: A systematic review of the available evidence [J]. World Journal of Emergency Medicine, 2017, 8(4): 245-252.
[11]	Chennappa Kalvatala Krishna, Hakim Irfan Showkat, Meenakshi Taktani, Vikram Khatri. Out of hospital cardiac arrest resuscitation outcome in North India — CARO study [J]. World Journal of Emergency Medicine, 2017, 8(3): 200-205.
[12]	Ji Ung Na, Sang Kuk Han, Pil Cho Choi, Dong Hyuk Shin. Effect of metronome rates on the quality of bag-mask ventilation during metronome-guided 30:2 cardiopulmonary resuscitation: A randomized simulation study [J]. World Journal of Emergency Medicine, 2017, 8(2): 136-140.
[13]	Gan-nan Wang, Xu-feng Chen, Li Qiao, Yong Mei, Jin-ru Lv, Xi-hua Huang, Bin Shen, Jin-song Zhang. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: A meta-analysis of 2 260 patients with cardiac arrest [J]. World Journal of Emergency Medicine, 2017, 8(1): 5-11.
[14]	Marion Leary, David G. Buckler, Daniel J. Ikeda, Daiane A. Saraiva, Robert A. Berg, Vinay M. Nadkarni, Audrey L. Blewer, Benjamin S. Abella. The association of layperson characteristics with the quality of simulated cardiopulmonary resuscitation performance [J]. World Journal of Emergency Medicine, 2017, 8(1): 12-18.
[15]	Mario Kobras, Sascha Langewand, Christina Murr, Christiane Neu, Jeannette Schmid. Short lessons in basic life support improve self-assurance in performing cardiopulmonary resuscitation [J]. World Journal of Emergency Medicine, 2016, 7(4): 255-262.