What is a defibrillator or AED?
A defibrillator is a computerised medical device delivers an electrical current through the chest which aims to shock the heart back into a normal rhythm allowing it to pump again. Rapid response using automated technology can significantly improve the quality of life of a survivor, as the longer the brain is starved of oxygen, the more damage that can occur. An AED is a portable defibrillator especially designed for people with little or no medical background. When
applied to the victim, voice commands and screen messages will guide the user step-by-step through the process and its intelligent technology will only allow it to shock a ‘shockable’ heart rhythm. AED technology opens a window for the public to take on a key role to support emergency services who would otherwise be hindered by the time it takes to reach the victim. It is argued that AEDs should be as broadly deployed as fire extinguishers and first aid kits.
Is there a need?
Sudden Cardiac Arrest happens around 140,000 times a year in the UK, making it one of the UK’s largest killers – equivalent to a jumbo jet crashing every day! The potential for saving a life is dependent upon time, the faster medical help can be attained, the better the chance of survival. Clinical studies suggest you have less than 5 minutes from the event to save the life, this decreasing by up to 23% per minute. In rural areas it takes time to get medical help, so Community Public Access Defibrillators (cPAD) have a very important part to play in helping save lives in rural communities. cPAD schemes are reckoned to be about 10x more effective in saving life post hospital than other community schemes alone. Your community needs to decide if you want one, but as SCA can happen to anyone at any time, and is not age related, better safe than sorry! Try timing yourself from your nearest Ambulance station.
The UK resuscitation Council guidance on having an AED in a community is whether an AED can be at the patient within 5 minutes of the SCA event happening, regardless of whether it is a cPAD scheme or a community responder scheme. If this cannot be achieved then your community may require a cPAD box and AED in addition to anything else you have available.
Is my community signed up and supportive?
Need is driven by local communities who by definition of request for the cPAD project have indicated their support. Around country these projects are driven by local groups like first aid, community responders, parish councils or Lions and Round Table who engage the support of the local communities, and co-ordinate fund raising and placement with the support of organisations like the Community HeartBeat Trust (CHT). Many ambulance services have active programmes too, and most work closely with the CHT.
Is there a minimum number of people needed to have a cPAD scheme?
No. So long as there is one person supporting this, then this justifies the effort. There are already local unstructured schemes being established by householders individually in your community, and your village hall may already have a defibrillator hidden in a cupboard, or someone’s house. Your local doctor surgery will have one too, but it is only available when the surgery is open. This project is about utilising these resources better to save more lives.
How many people do we need to be trained?
The UK RC guidelines suggest AED equipment is available to be used by everyone, trained or untrained. The CHT community awareness programme allows for this. However training of the local community is always desirable. Actual numbers are in reality unlimited. Training is sometimes done by your local ambulance service but is normally done through CHT, or with a local CHT authorised training organisation. Do not try to do your own training without Liability insurance.
Who delivers the training, to what specification and is the training free of charge?
Training is provided by CHT, or a local CHT approved training company, or by the local ambulance service. The CHT ‘Heartbeat’ scheme has a package designed with the ambulance service to meet the needs of community defibrillation schemes, and we can also arrange an HSE certified training packages as well. If a community opts to take extra training beyond that offered, then the local training organisation
is always at liberty to charge for that extra service in agreement with their local community project. The CHT training package is nationally set and meets relevant needs, as well as the defibrillator manufacturer’s standards. CHT will ensure the trainers to meet their exacting standards before
allowing them to undertake the CHT course. Training also allows you to move around the country, and be certified anywhere to undertake a cPAD use, or first aid. CHT recommends that the basic AED and cPAD awareness (2 hrs) training should be included in the initial delivery, but this is at the behest of the local trainer. Note there is no need to have trained first aiders before using AED equipment.
We have a local BHF Heartstart course
Can this suffice for training? Heartstart is a good awareness training for CPR and heart attacks and we encourage you to undertake this where available. It is not designed for AED training specifically, nor specifically for cPAD schemes. It is good to integrate this programme, however, as part of your local community awareness. The CHT
‘Heartbeat’ course covers how to recognise an SCA, what to do, how to act, how to undertake CPR and use the Defibrillator as well as details of your local scheme. This makes it a full and complete course that gives the attendees a long term useful skill set.
Do we have to be Community Responders?
No. CFR schemes are independent of cPAD schemes, but clearly trained responders can also use the cPAD equipment in an emergency, particularly if they are off duty and don’t have access to their own equipment. If you wish to establish a CFR scheme, this a matter for you and the local ambulance service and not the Community HeartBeat Trust, although
the CHT does, and will, support the establishment of CFR schemes. It is hoped that by having a cPAD scheme locally then this will encourage local communities to join first aid and CFR schemes. Many cPAD schemes are being established by CFR groups or ambulance services. Very few CFR schemes offer a 24/7/365 cover for a community whereas a cPAD scheme is readily available. The two are completely complimentary and not competitive.
What are the procedures for using the defibrillator?
Always call 999 and follow the instructions from your local ambulance service. The UK Resuscitation Council (UKRC) are the definitive guide to using cPAD equipment in the UK. CHT will only support recognised UKRC protocols. Activation protocols will be in line with your local ambulance service requirements.
How is the cPAD activated?
In all cases dial 999 first. It is really important the professionals are on their way. Your local ambulance service will notify you if there is a cPAD box near to you and if it is easily accessible, and give you the access code to the box. If you are willing they will ask you to get this and commence the relevant actions. Under the CHT scheme any trained volunteers can also have the access code and also the location where the box is sited. However this will vary from one ambulance region to another to meet their requirements.Always dial 999 ambulance.
Note please do not assume that the local ambulance service will automatically register the defibrillator on their system. You will need to meet their liability requirements for this to happen, and in many case sign an agreement for the defibrillator site. Also there are several internet based defibrillator locator websites that claim to offer registration of the defibrillator. These DO NOT guarantee that the ambulance service will be notified. CHT undertake all notifications and verifications for the ambulance service on any site we have been involved with, and provide the ambulance services with the correct information. All CHT sites need to be managed through the WebNoS system, that links to the ambulance service.
What Governance Processes are in place?
Governance is very important. Full records of the defibrillator, its installation, history of checks and use, all need to be maintained. Storage has to be in line with various laws and regulations, and in line with Department of Health guidelines. All equipment should be warranted by the manufacturer, and also be developed and produced to ISO 9001/9002 standards. In some cases the manufacturer will also indemnify any user of their equipment. All cPAD locations and codes are notified to the local ambulance service (fire and police too), who record on their control systems. All CHT supplied cPAD boxes give instructions to call 999. Daily, weekly and monthly checks are done on the cPAD equipment by the local scheme co-ordinator (who will be recognised by the ambulance service), and in some cases by the local ambulance service themselves undertake this too, to ensure fully operational equipment. CHT is not responsible for the maintenance of the cPAD installations, only to assist in their provision. CHT can advise on local insurance policies if required through the appropriate insurance broker. All equipment is guaranteed by the manufacturers, and monitoring and control systems have been agreed with most ambulance services to meet their local needs. All records are kept centrally through the WebNos system, and so is available to all stakeholders.
What long term support is there in place?
The defibrillator manufacturer will support the service for 7-8 years, this being the nominal life of the defibrillator and guarantees on the equipment. CHT have also negotiated an optional replacement service for supplies with the manufacturers, and also run service contracts.
Who will be the responsible person to carry out regular serviceability checks on the machine replace batteries, pads etc and replace items following the use of the machine, downloading of information etc.?
CHT can provide service contracts for replacement consumables, etc. This will be enacted by the local scheme. Local regular checking is undertaken by the supporting group through a checklist supplied, or by the local ambulance service. This is all recorded on the national WebNoSTM system which gives a direct link to the ambulance service and helps them recognise the ready state of the defibrillator. It also addresses liability issues. The CHT scheme is unique in that it offers a local group support free where a service agreement is in place. Your local ambulance service may wish to download the data from your AED and will have their own procedures for this.
How are these schemes funded?
Usually through public donations and fundraising, sometimes with local commercial and parish council grants support. As the Community HeartBeat Trust is a registered charity, local groups donate monies to CHT, in return we can donate defibrillators. CHT aims to be
able to provide grants for the establishment of cPAD schemes and works in co-operation with other funding charities. It also negotiates the best possible prices for equipment. CHT makes no profit from equipment provision, and relies on public donations and gift aid for funding the charity.CHT staff mostly work as volunteers and take no salaries, so all monies are used for the benefit of the communities being served.
If the defibrillators and equipment are to be purchased by communities should they have a choice of a range of defibrillators?
A community can always purchase their own equipment outside of a CHT project. In this case we are able to offer advice only.CHT supports the use of specific
AED equipment where possible for very good reasons, which can be provided on request. These include easy of training, support, ease of use, price, reliability and robustness. These include the same equipment as used in the national defibrillation project funded by the government and the national lottery, ie.the same equipment you see on stations, shopping centres and sports centres. We also
work with your local ambulance service to make sure it is equipment they are happy with. We do not recommend non-standard equipment. Standardisation means you are able and confident to use one wherever you are and are not faced with new challenges when an emergency arises. Most makes of defibrillator are available if desired but if a community chooses to use another manufacturer, or has one already, then this falls outside of the CHT scheme. There are of course, no restrictions on a local community choosing any manufacturer or AED, but this defeats the objects of standardisation, and may lead to delays in servicing a cardiac arrest. We always suggest you seek advice from your local ambulance service and see what they are prepared to support.
Will CHT support our local Community Responder scheme as well? Does this replace the need for Community Responders?
The CHT objects are to support cPAD schemes as well as support for CFR schemes - In fact any situation that supports the placement of AEDs into communities. Many cPAD schemes are run by the local CFR scheme to support their CFR activity and we would be happy to put you in contact with some CFR schemes that have done this. We will therefore support CFR schemes as well as cPAD schemes, and also local training and awareness schemes.
What is the specification of the cabinet?
CHT is able to source many different types of AED cabinet as cost effectively as possible. CHT also has its own range of cabinets designed for specific sites and purposes, ensuring the right cabinet is available for the right location. The high visibility yellow CHT cabinet range are secure, vandal resistant IP65 certified (in its end user configuration) and contains a thermostatically controlled heater, lighting and indicator lamps. It is manufactured to all relevant BS
EU standards, and is the only cabinet we provide that meets all these standards. CHT is not
responsible for which electricity supplier is chosen by a local community, but will require it to be fitted by a certified electrician. Cost of running is estimated to be about £3-£20 per year. Normally shops, pubs and village halls house the units and supply the electricity. Permission of the owner of the building will be required. Many sites use adopted telephone kiosks as locations and CHT has an arrangement with BT in this respect.
Why is the CHT box yellow?
There is no international or UK requirements for AED boxes to be a specific colour. CHT worked with the ambulance service and members of the public, as well as seeking the advice of the DH, UK RC and ERC, to ensure the boxes provided are highly visible and therefore easy to find in poor light conditions. It was felt by the reviewers that 'medical green' and
other dark colours made the boxes harder to find, and as this is about time to patient, then the easier it is to find a cPAD box the quicker the AED is to the patient. The choice of 'Traffic Yellow' is as a result of this consultation process, and the same colour as used by local councils and highways for easy recognition. It also complies with highways guidance if the cabinet is to be within 4m of a road. Most ambulances are also yellow now for the same reason. In reality if you wish another colour, we can provide at a cost, but most ambulance organisations and other medical organisations spoken to and who have seen the CHT box agree and endorse the yellow colour, and in some parts of the country
will insist on standardisation of cabinet colour as being yellow for cPAD sites. There are no regulations or approvals for cabinets colour, BUT there are regulations regarding the signage on the cabinets. The ERC/RCUK guidelines insist on the signage being green and ‘stand out from the background colour of the cabinet’ - CHT yellow cabinets meet this requirement, as well as adhering to HSE and safety legislation, as well as disability legislation – the only ones available that meet all these requirements. Beware of copies! Several manufacturers now copy the CHT design of cabinet!
“The RCUK do not make any recommendation about cabinet size or colour” – UKRC 2009
“Neither ILCOR or ERC impose a regulation about the color of the boxes”–ERC 2010
Do we need planning permission for a CHT box?
Not normally. Planning permission is not normally required as this is emergency medical equipment, and is classed as ‘diminimus’ in planning terms. CHT is not responsible for gaining local planning consent if required. This is the responsibility of the local group. To date all local authorities contacted have agreed planning permission will not be needed but listed building consent may be if applicable to the location. If in doubt ask your local authority for advice and build the cost into your fundraising.
Do I need an electrician to fit the cabinet?
Yes. Whilst several suppliers may say that no electrician is required as their version of defibrillator cabinets have a ‘flying lead’ and a plug fitted, these are outdoor cabinets and run of mains electricity. Therefore if there is already a plug fitted, it has to plug in somewhere! For external sockets these have to be fitted and certified as being safe by an electrician anyway, so if you have to fit a socket (which has to be dedicated and also not be able to be switched off or the plug removed) then this socket needs to be fitted with an RCD unit and certified anyway. If a socket exists, for health and safety reasons and to protect you from liabilities relaying to electrical safety, then this needs to be certified by an electrician. The cabinets must be powered at all times. Hence it is better to have a dedicated installation, which can be secure, and meet all the required health and safety rules. In addition, the CHT cabinets are electrically tested prior to leaving the factory and the installation by an electrician can be certified. If you are using a telephone kiosk, there are no sockets to plug into anyway, hence again an electrician is needed. In balance, having a flying lead and claims of no electrician needed, if misleading and false. If internal, no heating is required, hence no electricity.
If the local ambulance service directed a person to a cPAD site and when they arrived the box had no defibrillator in the cabinet or when it was attempted to be used for some reason it failed to work, would we be at serious risk of prosecution?
Unlikely. It is rare for thefts to occur. All due process is taken to reduce the risk to the equipment malfunctioning or not being available, and your community will be required to undertake weekly and monthly checks to ensure the equipment is functioning, and report this to CHT and to the local ambulance trust via the WebNoS Governance system. The cPAD box is vandal resistant, and checked weekly by the local scheme co- ordinator/ambulance organisation. There are procedures in place for consumables replacement. This is a scheme that exceeds that currently in place in shopping centres and stations, where the same issues could arise with unlocked cabinets. The Community HeartBeat Trust scheme is supported by other major charities and all Ambulance organisations. By dialling 999 you are also covered by the Ambulance Trust insurances, and protected from liabilities.
Do I need indemnity insurance to use one?
No. The patient is to all intensive purposes 'dead' when you arrive. Using CPR with a PAD will hopefully bring them back to life. No one will complain about that! However, calling 999 and taking instructions from the ambulance service will automatically cover you anyway under their insurances. Remember that you must call 999! A very good guide to this area is published on the website of the UKRC. However, CHT has agreed ‘Good Samaritan’ insurance for local communities that have cPAD schemes, if a community feels this is required. You will need to consider Public Liability insurances though.
Do I need theft and damage insurances?
Your choice. If a Managed Solution from CHT these are included. However it is always advisable to have insurance. CHT can direct you to a broker that has specialist insurance in this area where we have negotiated a package. CHT is regulated under the FCA as an introducer for Balens Insurance.
How closely does CHT work with the ambulance service?
Very! The CHT is a registered charity with its own board of Trustees, most of these are medically qualified in some form. In addition, some ambulance services have a representative on our management. Whilst it is easy to assume that all ambulance services have the same policies, this is not the case and there are variations across the country. By having the ambulance service integrated into our management we are better able to reflect the needs and requirements of your local service. This was typified by the design of our cPAD box, for example, which was jointly designed with the UK ambulance services, the only one to be so designed.
How do we go about getting a cPAD scheme running?
Simply send us an e-mail through the website and we will send you the relevant information and forms. We will also notify the local ambulance service of all enquiries we receive and if these become formal, we will send them copies of the registration forms. It may be that the local ambulance service already has a strategy for your local community and thus it is important this is reflected. CHT undertakes all registration of the equipment with the ambulance authorities and helps run the national defibrillator database.
How do we address the ‘lone rescuer’ situation?
In about 30% of cases, the rescuer is alone with the patient, and will be told to stay with the patient by the ambulance service. In this instance how do you get the defibrillator? CHT has developed the VETS™ scheme (Village Emergency Telephone System) to aid communities in this type of rescue. Using telephone technology, a village has a single emergency number they can ring if required to alert up to 10 volunteers to bring the defib, or otherwise assist. This has to be activated by the rescuer and not by the ambulance service (currently). The cost of this is a fixed price per year.
What about children?
All modern AEDs can be used on children. Under 8 years old/25Kg paediatric electrodes should be used, but in their absence an adult configuration can be used (ref:RCUK), but with anterior/posterior electrode placement. CHT do not currently favour the use of pediatric ‘switches’ due the to potential for error in use, as a result of misunderstandings as to what constitutes a ‘child’. We advise best practice in an under 8 as being paediatric electrodes, but only if a there is a child at risk, and not to store the electrodes in the cabinet with the main equipment, as this might cause delay or confusion in a rescue. A cardiac arrest will occur in an under 8 in UK primary schools typically once every 30-60 years – ie very rarely. Secondary schools are different and a much higher incidence. Children at secondary schools, or over 8 y/o, are treated as adults and do not use paediatric electrodes.
We have a telephone kiosk. Can we use this?
CHT is working with BT in the adoption of redundant telephone kiosks and the conversion of these into defibrillator sites. Many communities do not realise they have no right to access the electricity available in the kiosk. The kiosk adoption contracts expressly state this, and community will be in breech of this agreement if they ignore their contract. This is an ‘unmetered’ supply, and as such may not be access by the community for any use other than to power the 8 watt light in the kiosk. Any community accessing without due process may result in significant costs and fines for BT, and themselves. BT reserve the right to remove this power facility at any time.
As part of the BT sponsorship of the CHT charity, they allow (donate) the electricity to the charity, so that where CHT is involved, any project can access the electricity. CHT in return maintain a national register of telephone kiosks that have been converted to defibrillator sites.
Some retailers, some manufacturers of defibrillators and cabinets, as well as some funding organizations, are incorrectly advising communities they can install equipment into kiosks and access the power routinely. This is not correct, and such misleading advice is asking the community to commit a crime, and may also bring liabilities to the advising party.
In addition, some makes of cabinet may not be manufactured to BS7671 standards for electrical safety and thus should these be used in kiosks, they may present a safety issue to the community, as well as a vicarious liability to BT. BT have therefore asked CHT to ensure and guarantee the safety of the equipment to be installed into kiosks, and that such an installation is done by a competent and registered electrician, with a installation certificate issued. CHT provide the installation instructions for telephone kiosks.
CHT always advise the use of a qualified electrician, and not to use ‘plug in’ cabinets. This is on advice from our legal advisors, as well as our insurers.
CHT has a range of Hi Visibility IP65 cabinet styles to suite different needs, and locations. The ‘top of the range cabinet was uniquely designed in 2mm stainless steel, is the only one that meets all statutory requirements as well as being registered medical equipment. It is IP 65, which means full weather protection (unlike IP X4 cabinets, or those adapted from electrical cabinets). It is SIRA
certified and made to ISO 9002 standards, and has unique features that help its workability in situ. It is fully HSE and electrical safety standards checked, and carries the relevant safety markings for electricity. The cabinet is serial numbered, with all components checked and serial numbered as well. This is for the storage of medical equipment and must meet stringent regulations to reduce the possibility of liabilities. It is the only cabinet that fully complies with the Dept of Health guidance on storage of defibrillators, as well as relevant disability, highways and other regulations.
CHT do not use gimmicks such as ‘remote opening by mobile telephone’ for several reasons. Firstly this is medial equipment and needs to be used FAST. Placing gimmicks that can delay access to the equipment is not advised. As such we only use high quality marine grade stainless steel locks (to reduce to possibility of corrosion), simple and agreed access codes that have been pre-agreed with the local ambulance service, mechanical locks not dependent upon electricity to function, and are independent of any possible reduced signal for telephony, or errors in transmission. In addition we are not aware of any ambulance service that uses, or has endorsed, any remote opening device as this would place the ambulance service in a liability situation. These remote opening devices also do not meet RCUK specifications.
Most ambulance services are looking to standardise on cabinet colour for communities as this also reduces time to gain access for the defibrillator. The colour chosen by most is yellow.
The defibrillator chosen must be robust, and approved off by the local ambulance service as they will be responsible to download information etc. Avoid unknown makes or those without a good history of reliability. Choose ones with a good running cost, and use medical lithium batteries, not consumer type batteries. Also defibrillators where it does not matter if the electrodes are paced the wrong way around as members of the public can under stress make errors. CHT has to date delivered Cardiac Science G3 and G5 equipment, Laerdal FRx, Physio Control CR+, DefibTech VIEW and also CU-SP1 equipment. Whichever you use must be backed by a proper Governance programme.
Governance is essential. You MUST comply and have in place good governance for your installation. Most ambulance services will insist on seeing your governance plans, or have you sign an undertaking before they will activate your defibrillator. Working through CHT automatically covers you, via the WebNos Governance system.
UK DEPARTMENT OF HEALTH requirements for medical devices April 2014:
“Good record keeping is essential for the safe management of medical devices. All the aspects of medical device management … require some degree of record keeping. The records should be maintained within one system wherever possible.” “Accurate and complete copies of records in paper or electronic form are required to be made available for future inspection, review and copying e.g. for CQC, internal audits, traceability, investigations.”
MHRA guide to defibrillators April 2012 :
“Up-to-date records of location, service and maintenance should be kept for all medical devices”
American Heart Association guidelines 2014:
‘It is important to do a weekly or monthly visual inspection of the AEDs to ensure they are in working order - the program coordinator or another designated person can do the inspections. This person develops a written checklist to assess the readiness of the AEDs and supplies. A checklist supplements regularly scheduled, more detailed inspections recommended by the manufacturer.”
WebNos is the UK’s most comprehensive management tool for keeping track of all aspects of Governance for defibrillators. The system not only allows regular checks to be maintained, but also allows for a complete and holistic record of the device to be made available to the Coroner in the event of a death. WebNos enables:
- Initial installation records, and equipment manifest
- Weekly, Monthly, Annual checks in line with DoH recommendations
- Instant reports to record usage of the defibrillator, reporting out of action and back in action details.
- Reporting to the Resuscitation Council on rescue details
- Training records
- Equipment consumable resupply
- Statutory notifications
- Coroner records
- Shared data across all stakeholders
- A full history of the equipment, its usage, changes to the configuration, battery and electrode replacement dates, and other required audit information.
The WebNos service is free to all clients of the Community Heartbeat Trust charity, and to ambulance services in the UK. A community will be automatically registered into WebNos and many ambulance services are now making it a requirement under their MoU’s with communities.