Public Access Defibrillation (PAD) in Schools

Since May 2000, the State Education Department (SED) has been working with the State Department of Health (DOH) to explore the use of automatic external defibrillators (AEDs) in schools. In July 2000, a working group from the education and health fields met to discuss AEDs and their potential placement in the school setting. The group was charged with preparing a document to provide information to schools to inform their decision-making process about the use of AEDs in the school setting.

You can either read the document here (online/below) or download either a
Microsoft Word Version (38 KB) or an Adobe Acrobat version (29 KB).

PUBLIC ACCESS DEFIBRILLATION (PAD) IN SCHOOLS

Background

Although sudden cardiac deaths occur more commonly in adults (225,000 adult deaths annually)¹, an estimated 5000 to 7000 children (without symptoms) die suddenly in the United States annually.²Approximately 40 children and adolescents (5 to 18 years of age) die annually in New York State from diseases affecting the heart.³This contrasts with approximately 20,000 cardiac deaths in adults (21 to 74 years of age) annually in New York State.³ Current research suggests that the vast majority of sudden cardiac deaths in children and adolescents are directly related to undetected cardiac anomalies.

Cardiac arrest is an abrupt disruption of the heart function causing lack of blood flow to vital organs. Abnormal heart rhythms are the cause of most cardiac arrests. Ventricular fibrillation, a specific type of chaotic heart rhythm, is the most common abnormal rhythm associated with cardiac arrest. The treatment for ventricular fibrillation is defibrillation, shocking the heart into a regular rhythm. Untreated cardiac arrest due to ventricular fibrillation ultimately leads to cardiac death.

The emergency response to cardiac arrest includes early access to emergency medical care, cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced cardiac life support. Today, a new generation of defibrillators, called automated external defibrillators (AEDs), makes it possible for trained lay rescuers to deliver defibrillation. Nationwide and within our state, the concept of public access defibrillation is growing in popularity.

Sudden cardiac death in children and adolescents is a devastating event that raises anxiety and concerns within the general community. The purpose of this document to provide information that can be helpful to school personnel as they review their current emergency response procedures and consider the use of automated external defibrillators.

What causes sudden cardiac death in children and adolescents?

The most common cardiac causes of sudden death are specific conditions present since birth. These include:

Hypertrophic cardiomyopathy (an enlargement of the heart)
Congenital coronary artery anomalies (the blood vessels around the heart are abnormal)
Aortic stenosis (narrowing of the aorta)
Other heart abnormalities
Dysrhythmias (abnormal cardiac rhythms).

Sudden death may also occur in young sports participants, with normal hearts, when a projectile strikes the child in the chest. This phenomenon is termed commotio cordis (heart concussion) and predominantly affects children and adolescents 5 to 15 years of age without preexisting heart disease.⁴Commotio cordis has been reported in baseball, ice hockey, lacrosse, softball, and as a consequence of fistfights. This is a very rare cause of sudden death resulting in 45 reported deaths in the U.S. annually.

It is important to note that abnormal cardiac rhythms can also result from body fluid problems. Two examples include:

sweating routines to achieve rapid weight loss.
dehydration resulting from anorexia and bulimia.

What are the risks for sudden cardiac death in schools?

In general, children and adolescents are at low risk for sudden cardiac arrest. Cardiac arrest in children and adolescents has usually been attributed to respiratory causes rather than heart factors. However, cardiologists are beginning to think that ventricular fibrillation in children may be more common than previously thought. Sudden death related to undetected cardiac anomalies appears to occur most often among high school athletes. There are approximately 12 deaths per year in U.S. high school athletes.⁵

Sudden cardiac death occurs much more commonly in adults. In addition to those adults employed by schools, community groups use the school building for various events. Many school districts extend the use of school buildings to senior citizens, the population at greatest risk for sudden cardiac death.

Treatment of sudden cardiac arrest

The American Heart Association has developed a "chain of survival" that provides a framework for emergency response to cardiac events as follows:

Early Access - to emergency medical care through 911 or other emergency number
Early Cardiopulmonary Resuscitation (CPR) - to provide oxygen to vital organs, including the brain
Early Defibrillation - to return the heart to its normal rhythm
Early Advanced Cardiac Life Support - to stabilize the victim

Sudden cardiac arrest in children and adolescents can lead to ventricular fibrillation. During ventricular fibrillation, the heart's electrical impulses become chaotic and the heart no longer pumps blood effectively. Defibrillation is the definitive treatment that treats ventricular fibrillation and restores a functional heart rhythm. When a person suffers a sudden cardiac arrest, their chance of survival decreases by seven percent to 10 percent for each minute that passes without defibrillation.⁶

Public access defibrillation programs allow trained lay people to use an automated type of defibrillator in combination with CPR. An automated external defibrillator (AED) is a device used to administer electric shock through the chest wall to the heart. Built-in-computers assess the individual's heart rhythm, judge whether defibrillation is needed, and then administer the shock. Audible and/or visible prompts guide the user through the process.⁷

Some medical experts suggest that the use of this new technology might increase the initial survival rate of cardiac arrest victims from two percent to as much as 40 percent. There is ongoing research regarding outcomes from the use of AEDs.

The New York State Public Access Defibrillation Program

Late in 1998, Governor Pataki signed into law the Public Access Defibrillation Law, ensuring wider use of a remarkable new technology that can "jumpstart" an arrested heart. The Public Access Defibrillation Program seeks to place AEDs at a number of locations to ensure greater public availablility.

Individuals and organizations making a good faith effort to provide urgently needed medical attention are protected by the Public Health Law (Article 30, Section 3000-A), sometimes referred to as the Good Samaritan law. This guarantees that any person who voluntarily and without expectation of monetary reward provides emergency treatment will not be liable for damages for harm alleged to have occurred, unless it is shown that he or she is guilty of gross negligence.

To be authorized to use an AED under New York State law for PAD (Chapter 552 of the Laws of 1998) an individual or organization needs to make specific notification of intent to the local Regional Emergency Medical Services Council and the State Department of Health. Written practice protocols and policies for the use of the AED must include:

Training designated rescuers in CPR and how to use an AED.
Having physician oversight to help ensure quality control.
Integrating with the local emergency medical services (EMS) system.
Using and maintaining AEDs according to the manufacturer's specifications.

Schools as a location for a Public Access Defibrillation Program

Schools must be prepared to manage medical emergencies. Each school should have a current emergency plan for the school that is periodically updated and practiced with drills and other exercises to test its components. This emergency plan should include policy and procedures on how to handle sudden cardiac arrest in students and adults that both work at and/or routinely visit schools for a variety of reasons, including sporting events.

The plan to handle sudden cardiac arrests in the school might include implementation of a Public Access Defibrillation (PAD) Program. The decision about implementing a PAD Program is a local decision. The board of education should obtain wide community input regarding this important issue. The decision can best be made by considering the school environment and assessing the risk of sudden cardiac arrest within the school setting.

Important general considerations include:

children and adolescents are at low risk for sudden cardiac arrest
AEDs are not currently recommended for use in children under 8 years of age or under 80 pounds
sudden death related to undetected cardiac anomalies appears to occur most often in high school athletes
teaching staff, school support staff and other adults use school buildings and attend school-sponsored events
adults over age 50 are five times more likely to experience sudden cardiac arrest than children and adolescents.

School specific factors to consider are:

the age and cardiac histories of school staff
the types of activities and events hosted in the school buildings and the populations in attendance
the types of policies and procedures that are already in place to support student and staff wellness (required physical exams, injury prevention efforts, etc.)
the attention currently given to the use of protective sports equipment and equipment safety measures
whether there is a history of student or staff deaths
the availability and response times for emergency medical services including 911 access and PAD availability among first responders such as police, ambulance and fire departments
the relative effectiveness of the school's curent emergency plan in dealing with sudden cardiac and other emergencies, and how the use of AEDs would fit with the rest of the emergency plan
consideration of legal issues such as informed consent.

Schools need to have a comprehensive emergency response plan, which is coordinated with the local emergency medical service system. If PAD is chosen to be part of the school's emergency plan, it is imperative that adequate planning and support for the program be available. Key elements of a school-based PAD Program include:

a core emergency response team of trained personnel, including the school nurse, and a method to activate this team
a well-defined emergency plan that clearly states all policies and procedures relative to the use of AED
strategic placement and availability of the AED unit(s)
a rapid and effective communication system, especially with regard to events held at remote locations
training of appropriate staff in CPR including the use of AED
regular maintenance of the AED unit(s) according to the manufacturer's specifications
periodic testing and repair/replacement of non-functioning units
reporting the use of AED to the collaborating emergency health care provider, who in turn is required to report to the regional Emergency Medical Services Council
physician oversight.

How can schools help reduce the risk of sudden cardiac death?

The prevention of heart disease in adults begins in childhood. Schools can help promote healthy hearts by encouraging healthful behavior in students and staff. The five major risk factors regarding heart disease are: tobacco use, high cholesterol, elevated blood pressure, obesity, and lack of physical activity. A coordinated school health program offers many effective strategies to address student and staff health promotion and risk reduction strategies.

To help prevent the occurrence of sudden death in young athletes, school sports programs should follow current clinical guidelines for performing a sports preparticipation health evaluation (PPE). Specific information about the PPE can be found in Care of the Young Athlete developed by the American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP), 2000.

For further information on:

The New York State Public Access Defibrillation Program -- contact:

New York State Department of Health
Bureau of Emergency Medical Services
433 River Street, Suite 303
Troy, New York 12180
Phone: (518) 402-0996
Fax: (518) 402-0985

Coordinated School Health Program Planning And Implementation -- contact:

New York State Education Department
Student Support Services
Washington Avenue, Room 318M-EB
Albany, New York 12234
Phone: (518) 486-6090
Fax: (518) 474-8299

Workgroup

This document was developed with the help and support of the following individuals and organizations:

American Academy of Pediatrics
New York Chapter 1
Dr. Cindy Devore

Suffolk County Department
of Health Services (Division of EMS)
Dr. Jeanne Alicandro

American Red Cross
Christoper Burke

American Heart Association
Donna Kopec

New York State Public High School Athletic Association
Lloyd Mott

New York State Council of School Superintendents
Phillip Langton

New York Medical College
Dr. Paul Woolf

New York State Association of School Nurses
Deborah Ilardi, RN
Cindy Kaiser, RN
New York State Nurses Association
Marsha Henderson, RN

SUNY Stony Brook
Dr. Mark Henry

New York State Department of Health
Dr. Christopher Kus
Edward Wronski
Frank Zollo
Michelle Cravetz, RN

References

¹American Heart Association, 1999.

^{2
Berger S, Dhala A, Griedberg DZ. Sudden cardiac death in infants, children
and adolescents. Pediatric Clinics of North America, Vol. 467(2),
April 1999; p.221. (Sudden Infant Death Syndrome (SIDS) deaths are
excluded from this estimate.)}

^{3
New York State Department of Health, Vital Statistics.}

^{4
Marion BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest
leading to sudden death from cardiac arrest during sports activities.
New England Journal of Medicine 1995; 333: 337-42.}

^{5
McCaffrey FM, Braden DS, Strong WB. Sudden cardiac death in athletes: a
review. American Journal of Disease in Children. 1991; 145:177-183.}

^{6
Statistical data taken from the American Heart Association. Heartsaver
AED. Dallas, TX: 1998, p.1-4.}

^{7
American Heart Association. Questions and Answers About AEDs. 2000.}