3.6.1 Findings from the 2004 reviewThe 2004 review examined a PAD program that was being delivered in the UK. The program:
- Developed an administrative structure including advisory committee
- Obtained support from key stakeholders including ambulance, community groups and health professions
- Determined the legal status of the those using the equipment
- Procured defibrillators
- Established pilot sites including training and
- Administered long-term management of the program.
A number of challenges were reported for the program including defining the legal status of lay-people who use AEDs, generating the enthusiasm and interest in the program and developing data collection mechanisms for evaluation. The progress of the program was reported to the public via a series of six-monthly bulletins.
The review concluded:
… the UK initiative represents a strong government approach to addressing cardiac arrest survival. It is nationally co-ordinated and funded, clinically led, involves the local community, provides web based resources and feedback, establishing mechanisms for data collection and system evaluation (Jacobs 2004, P.27).
3.6.2 Update: the UK experienceA number of developments have been noted in the UK approach since the 2004 review. The review extensively cites a paper by Davies (2002) which describes in detail the introduction of the PAD program in the UK. In the concluding sections of the paper, Davies looks to the future and suggests:
The Department of Health may not be the best place for the longer-term administration of the project however because operational activities such as this are not a key part of Department of Health work (p. 19).
A review of the program's website in 2008 has suggested that indeed the Department of Health in the UK has divested much of its role in the program to other organisations such as ambulance trusts and charitable organisations, thus completing the 'evolution' of the UK model.
Early stages of the UK modelThe PAD Program's website describes the early stages of the program:
In July 1999, the White Paper, Saving Lives: Our Healthier Nation announced the Government's intention to invest £1 million in installing AEDs in busy public places. A further £1 million was then committed to training people employed at the site in their use and in basic life support. (Department of Health 2008).
At this time, the program was entirely funded by the Department of Health who also provided governance and oversight of training and installation via a series of committees and panels of experts. In the coming years, this model was maintained as further funds were allocated and the implementation of AEDs under the program became more wide-spread.
The program was the object of much scrutiny from both the academic and health sectors, with many papers published on the process of implementation and outcomes arising from the use of AEDs.
The early stages of the implementation of the UK model appeared to be successful. The program’s website clearly states the extent to which AEDs have been taken up by the community, and the benefits that have arisen from AED usage.
700 AEDs have been placed at 110 locations across England and more than 6,000 volunteers have been trained in Basic Life Support skills. Current evidence suggests that 74 lives have been saved as a direct result of the work of the programme16 (Department of Health 2008). Top of page
The UK model todayToday, the way in which the model is implemented and governed in the UK is quite different to that described above. Described as the shift to 'Phase 2' of the program, key developments include the following.
- As of February 2005, the program became a 'Core NHS activity', which meant that ambulance trusts at a local level are now charged with all training and re-training of volunteers. Local ambulance trusts were also given responsibility for who would then receive a publicly funded AED (Department of Health National Defibrillator Programme 2005). This function had initially been provided by the 'defibrillator advisory committee' formed by the Department of Health (Davies 2002). According to the program's website:
In the current and final stage of the programme Ambulance Trusts across England have been invited to identify areas in their regions that would most benefit from the installation of AEDs and apply accordingly. Thirty-one trusts will now receive a share of the next 2,300 AEDs for their areas as well as a Community Defibrillation Officer to oversee and coordinate the necessary installation, training and management of these AEDs (Department of Health 2008).
Responsibility for the existing 400 sites established for the first phase of the program was also devolved to the local ambulance trusts.
- Funding for this second batch of AEDs was, however, not provided by a Department of Health budget measure. In 2003, six million pounds was provided directly to the British Heart Foundation via an allocation from the 'Big Lottery Fund' (BLF). The BLF:
… gives out millions of pounds from the National Lottery to good causes. Our money goes to community groups and to projects that improve health, education and the environment (Big Lottery Fund 2008)
A review of the Department of Health website suggests that the Department is no longer directly funding the purchase of AEDs.
Despite these changes, the UK program remains a centralised, relatively uniform and publicly funded model with many similarities to Australia. Top of page
3.6.3 Update: in stark contrast, the American experienceIn contrast to the UK approach, the US does not have one funding or legislative model for AEDs. Rather, America has 50 funding/legislative models, one per state.
Historically, AEDs first entered the legislative arena in 1998, when the then President Clinton signed the Aviation Medical Assistance Act that stated that "airlines and individuals shall not be liable for damages" in attempting to obtain or provide assistance in the use of AEDs on aeroplanes. This legislation was later expanded by Clinton in 2000 when he signed the Cardiac Survival Act providing civil immunity to authorised users of AEDs in public places. Additionally, this act also made provision of US$25,000,000 over two years for the appropriation of AEDs. Further legislative change occurred in 2002 when the then President Bush signed the Community Access to Emergency Devices (Community AED Act), a sub-section of the Public Health Security and Bioterrorism Act (obtaining funding under the banner of terrorism was common at that time). The Act provided for a further US$30,000,000 in funding for the purchase of AEDs, and training of staff and volunteers in their use (National Conference of State Legislatures 2008).
AED and PAD programs appear to be still very much on the American agenda. The advocacy group The American Heart Foundation plays a strong role in advocating for ongoing funding and is very vocal in its views in a range of publicity campaigns. In 2007, the Foundation published a series statements urging the federal government to release almost US$45 million, that had allegedly been promised in 2004 (American Heart Association 2007).
Between 1995 and 2000, all states introduced laws and regulations relating in some way to AEDs. Since 2000 many states have gone on to re-examine these pieces of legislation to facilitate the purchase of AEDs, and the implementation of AED and PAD-based programs. However, the introduction, funding and implementation of these pieces of legislation have been far from consistent from state to state (Aufderheide 2006).
The table on the following pages provides a summary of the way in which the 50 different states have legislated, funded and implemented AED and PAD-related programs.17
States have used a mix of approaches to roll out PAD programs, some using federal funding, some introducing legislation mandating the use of AEDs, others providing incentives to organisations to purchase and register AEDs. While all states have taken some action in this regard, some states have done very little. The table on the following page provides seven key pieces of information for each state:
- Whether legislation had been introduced that provided any form of protection for lay people to use AEDs (such as Good Samaritan legislation)
- Whether immunity from legal action had been provided to trained and authorised users of AEDs
- Whether federal funding had been appropriated for the purchase of AEDs and training of operators, and the amount of that funding where known
- Whether non-binding resolutions had been passed that encouraged organisations to take part in AED programs, but not mandating participation
- Whether changes had been made to legislation about training and liability requirements since 1998 (when AED legislation was introduced at the federal level)
- Whether legislation had been passed that mandated the purchase and maintenance of AEDs for certain businesses and
- Comments on the types of legislative change and funding arrangements implemented by each state. Top of page
- Almost all states (96%) have implemented some form of legislation that gives limited protection to lay-people using AEDs
- Almost all (90%) have introduced legislation that gives total immunity to people trained in AED use in the conduct of resuscitation using the device
- One third (30%) of states had received some form of federal funding of amounts between $100,000 and $3,300,000. Funding was obtained from a variety of sources, not all of which are relevant to the Australian context:
- Directly via the budget measures described above (states tended to re-badge the budget measure using their own program names such as 'First State – First Shock!')
- A small number of states obtained funding via a tobacco settlement fund
- One state established a 'donation partnership' with the American Heart Foundation that co-ordinated donations for the purchase of AEDs
- One state appropriated a small amount of funding ($100,000) but required organisations to make an in-kind contribution of 50% for the purchase of AEDs and
- One state facilitated the bulk purchase of AEDs at a discounted rate for distribution to schools.
- One fifth (18%) of the states passed non-binding resolutions with requests for actions such as the identification of suitable sites and liaison with AED manufacturers by state health departments, or generally encouraging (but not mandating) the installation of AEDs in selected businesses
- Two thirds (61%) of the states made recent legislative changes that provided some form of protection for either trained or untrained users of AEDs. The general pattern for these changes was two-fold: An initial revision to legislation that provided some form of immunity to trained users, followed by a second revision that broadened this protection (though often in a lesser form) to untrained users
- Three quarters (27%) of states introduced legislation that mandated the purchase and maintenance of AEDs in specified organisations. The most commonly mandated organisations were schools (typically public schools) 'fitness studios' and sporting venues. It was not clear whether funding was provided to these organisations following the legislation change
- Three quarters of the states introduced specific regulation that mandated the registration of AEDs, either with the state health authority or emergency services (based on additional information obtained from the American Heart Association 2008). However, one state took the unusual action of removing the requirement to register AEDs, presumably in an effort to reduce administrative burden.
16 CR&C has used the UK spelling of 'programme' in this section as it is reported in UK publications. Elsewhere, the Australian spelling of 'program' is used.
17 This table is based on summary information provided by the American National Conference of State Legislatures. A full review of specific legislation from each of the 50 states is beyond the scope of this review. Some of the information provided by this organisation is incomplete and is noted as such in the text.