This article was downloaded by: [University of Regina] On: 04 September 2014, At: 23:59 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a Novel Approach for Increasing Accessibility a
a
Ryan Berger & Jesse O’Shea a
Florida State University College of Medicine, Tallahassee Florida Accepted author version posted online: 13 Aug 2014.
To cite this article: Ryan Berger & Jesse O’Shea (2014): AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a Novel Approach for Increasing Accessibility, Journal of American College Health, DOI: 10.1080/07448481.2014.947993 To link to this article: http://dx.doi.org/10.1080/07448481.2014.947993
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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Viewpoint AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a
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Novel Approach for Increasing Accessibility
Ryan Berger1; Jesse O’Shea1 1
Florida State University College of Medicine, Tallahassee Florida
The authors contributed equally to this work
1
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Abstract. The use of AEDs increases survival in cardiac arrest events. Due to the success of previous efforts and free, readily available mobile mapping software, the discussion is to emphasize the importance of the use of AEDs to prevent SCA-related deaths on college campuses and abroad, while suggesting a novel approach to aiding in access and awareness
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issues. A user-friendly mobile application (a low cost iOS map) was developed at Florida State University to decrease AED retrieval distance and time. The development of mobile AED maps is feasible for a variety of universities and other entities with the potential to save lives. Just having AEDs installed is not enough—they need to be easily locatable. In a time where society increasingly relies on phones to provide information, there are opportunities to use mobile technology to locate and share information about relevant emergency devices and should be incorporated into the chain of survival.
Keywords: automated external defibrillator, cardiopulmonary resuscitation, college health, mobile health, sudden cardiac arrest
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ACCEPTED MANUSCRIPT Background A major issue in public health is sudden cardiac arrest (SCA). While sudden cardiac events are more common with increasing age, when experienced in younger populations they are often more deadly.1 Over 424,000 people experience emergency medical services (EMS)assessed out-of-hospital non-traumatic sudden cardiac arrest yearly and nine out of ten victims
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die.2 To put this into perspective, sudden cardiac death accounts for nearly ten times the number of individuals who die from breast cancer annually.3 Sudden cardiac arrest is a pulseless condition that occurs when the heart ceases to pump blood effectively or at all. When blood is no longer circulating in the body, the individual collapses and is considered clinically dead. A substantial obstacle in treating victims of SCA is time. Fortunately, as automated external defibrillators (AED) have become easier to use and more available, survival following SCA has subsequently improved. In one study, 11.4% of EMS-treated non-traumatic SCA victims survived. Comparatively, if treated with bystander cardiopulmonary resuscitation (CPR) and an AED before EMS arrival, survival rates climbed to 38%.4 A recent meta-analysis concluded that programs based on CPR plus early AED defibrillation by trained non-healthcare professionals offer a survival advantage over CPR alone.5 However, the effectiveness of an AED device depends on it being present or immediately delivered to the site of arrest. Regardless of their life saving potential, AEDs are of no value if they cannot be located and utilized effectively. Imagine a student, unconscious and without a pulse. A bystander immediately starts resuscitation efforts and EMS is en route; however, neither are aware that there is an AED less than 50 feet away in a nearby classroom.
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ACCEPTED MANUSCRIPT When compared to lower-level schools (preschool, elementary, middle) and high schools, colleges have the highest incidence rate of SCA.6 Between 1990 and 2005, the estimated annual incidence of SCA events in lower-level schools and colleges was 0.18 per 100,000 person-years among students and 4.51 per 100,000 person-years for school faculty and staff.6 More alarming, SCA in National Collegiate Athletic Association (NCAA) student-athletes is the leading cause of
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death, claiming one life per 22,903 participants in the 17-24 age range—up to seven times higher than previously predicted.7 While data on adult SCA is plentiful, current studies exposing the full scope of sudden cardiac arrest events in younger populations is lacking. Furthermore, routine sports physicals fail to detect many of the conditions that cause SCA in young adults; such as hypertrophic cardiomyopathy, valvular disease, and electrical disorders.8 Student deaths from SCA can trigger deep emotions among family and community members and raise concerns about the vulnerability of other school-age individuals. Such events have increased awareness of school-based rescue actions that include SCA recognition and emergency activation, early CPR, early defibrillation, and timely advanced care. Collectively, these actions are termed “links in the chain of survival”. These incidents have led numerous groups to advocate for AEDs in every school.9-12 Advocacy efforts have prompted legislation in several states requiring AED placement in schools, as well as a US congressional bill promoting access to defibrillators on school grounds.11-14 Recently, the media has featured several stories of individuals successfully using content on their mobile phones to save lives.15 Mobile phones allow responders to attend to victims during emergencies while simultaneously contacting emergency services. A recent study indicated a nearly six fold increase in the use of mobile phones for contacting EMS providers; an
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ACCEPTED MANUSCRIPT increase which appreciably decreased the time required to notify emergency45 providers of an incident.16 In 2009, researchers first developed a mobile AED mapping system in Japan. AED locations were mapped using information from Japan’s Public Access Defibrillation Program. Using a cell phone’s GPS, the application triangulated the user’s location and displayed a map of
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the nearest AEDs and their distances from the caller; names, business hours, and telephone numbers of the facilities were also displayed. A control group and a group with the mobile phone application were placed throughout Kyoto University and given a simulated SCA event. The study found that the group with the phone application traveled a significantly shorter distance (from victim location to AED) than the control group. However, the time for AED retrieval was not appreciably diminished. The researchers attributed this to the time needed to operate the application and limited cell phone data speeds. Also, participants were trained to use the system just prior to the experiment. The researchers suggested that a navigation system with a digital compass or a one-touch operation system may shorten the time of AED retrieval.17 “Crowdsourcing”, or “tapping the power of a crowd,” is a relatively new term with broad applications.18 By applying crowdsourcing to healthcare, patients are empowered with the tools needed to take charge of their own healthcare. An example of this technology is the AED4U program in the Netherlands, which consists of a website and mobile phone application where users, via their smart phones, can access, input, and share the locations of AEDs. 19 American universities have yet to take advantage of this mobile-friendly technology. Recently, a project called the “MyHeartMap Challenge” was implemented in Philadelphia. The project encouraged individuals to photograph, collect, and submit, either online or through a mobile application,
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ACCEPTED MANUSCRIPT supplemental information about AEDs users identified in the city. Participation was further incentivized with monetary prizes. The study resulted in the submission of 1,429 AED locations, 852 of which were unique, nonoverlapping, and confirmed as valid.20 The “MyHeartMap Challenge” demonstrated the effectiveness and potential of crowdsourcing for such tasks. Until recently, Florida State University (FSU), located in Tallahassee, Florida, lacked a
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physical or online map of campus AEDs. Other universities have already taken advantage of online technology use to map out AEDs, including the Georgia Institute of Technology.21 For example, Google provides free custom-mapping software, including step-by-step navigation, that is available in a mobile form.22 Building upon previous efforts, this discussion emphasizes the importance of AEDs in preventing SCA-related deaths on college campuses and suggests a novel approach to expand awareness and emergency access. A model application was implemented at Florida State University that was designed to decrease AED retrieval distance and time. This was based on ease of use, low threshold for implementation, low cost, and wide availability. The application was created using an existing mobile platform utilized by FSU and many other institutions. The application allows students, faculty, and visitors to easily identify the locations of AEDs on campus and will likely increase the chances of survival in the event of a SCA emergency. A Novel Approach The FSU AED application was designed to be incorporated into the SCA chain of survival (see Figure 1). After stakeholders were identified, our team was able to secure a list, although outdated and incomplete, of known AEDs from FSU’s First Responders. Stakeholders included the FSU Police Department, First Responders, building managers, and information
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ACCEPTED MANUSCRIPT technology services. The list was then used to locate, record, and photograph the AEDs and also to obtain their coordinates using Google Maps. A description of the AED’s location and a contact number was also documented. The locations of any damaged, inaccessible, or newly located AEDs were shared with First Responders. Once this list was compiled, our team contacted the FSU Office of Information
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Technology Services in order to incorporate the AED locations into the ‘Places’ section of the existing myFSU Mobile application. The existing application is Blackboard Mobile Central, which many universities already use, including FSU, Stanford, and Loyola. Any school using this platform may utilize this technology. Data obtained from the mobile devices was then entered into a .CSV file and uploaded onto the server. Once entered, the data was immediately live and automatically accessible to everyone with the myFSU Mobile application. With regard to updating the data, any changes made are reflected on the same day, as the server refreshes the data every six hours. From initial idea to live product, this project took approximately three months to complete. Physical data was gathered over a three day period by walking the FSU campus. Data entry into myFSU Mobile took two days. Identifying and corresponding with stakeholders required significant time due to the bureaucracy of a large university, the ambiguity surrounding stakeholders, permission granting, and difficulty scheduling with multiple parties. However, all parties involved were extremely helpful and optimistic in working to make FSU’s AEDs more accessible and transparent.
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ACCEPTED MANUSCRIPT The Outcome By clicking on the myFSU Mobile application, users can quickly access the list of campus AEDs. By clicking on an AED location, the user can access more detail, including a simple description of the unit’s location, approximate walking distance and time (from current location), map, and photograph. The user can also see the relationship of the unit to the campus
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at large, as well as their current location via GPS. The Augmented Reality mode automatically enables the user’s smartphone camera. Augmented Reality is an innovative new technology which leverages the iPhone’s camera and GPS to identify surrounding buildings in a 3D, interactive view. As the user scans their environment, the AED they are looking for is automatically overlaid in their visual field when they are pointed in the right direction, including the name of the AED unit and its approximate distance from the user’s current location. When viewing a map of all campus AEDs in Augmented Reality, the closest AEDs appear the largest. This application can be further explored by downloading the free application from the ‘App Store’. The Impact This project resulted in cataloging all known FSU main campus AEDs. Thirty-eight AED units were integrated into one mobile map accessible to more than 61,000 Apple iOS users and over 118,000 total active users of myFSU Mobile.23 The AED addition to myFSU Mobile will directly impact over 40,000 students enrolled at FSU’s main campus, as well as thousands more employees and visitors.24 Indirectly, this project created a greater awareness of CPR, AEDs, and SCA at FSU. This was accomplished by word-of-mouth and through publicity surrounding the project, such as local radio, news stations, and university press. However, there is no way to
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ACCEPTED MANUSCRIPT determine how effective these advertising channels were, and knowledge of campus AED units and cardiac arrest was not assessed prior to this project. This could be a goal of future implementations at other institutions. Moving Forward Sudden cardiac arrest in the college setting is a reality that must be adequately addressed.
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Recent studies have suggested that SCA in this population may be grossly underestimated, especially in regard to student athletes.7 Although heart disease is generally associated with advanced age, there are still at-risk individuals in younger populations, and college students have the highest incidence of SCA events when compared with children in grades K-12.6 This project demonstrates that the development of mobile AED maps is feasible for a wide variety of school districts, universities, businesses, and governmental entities with the potential to save lives. The Heart and Stroke Foundation of Canada made four key recommendations to the general public regarding public access to AEDs.25 These include (1) having widespread access to AEDs, especially in settings where SCA is of higher probability, (2) being trained and encouraged to use CPR and AEDs in a SCA event, (3) ensuring that targeted responders are adequately trained, equipped, and directed to use AEDs, and (4) registering AEDs with the appropriate authorities to ensure visibility and maintenance. The authors support these recommendations and suggest adopting mobile AED technology, similar to the project at FSU, to assist in reaching these goals. For schools that already utilize Blackboard Mobile Central, implementing an AED application is feasible and virtually cost-free. Currently, the ‘Places’ feature is only available on the Apple mobile operating system ‘iOS’ platform, so expanding this to other platforms would
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ACCEPTED MANUSCRIPT empower more users with this feature. However, for smaller campuses or those lacking this resource, a web-based version of an AED map would be a step in the right direction. The most important challenge in implementing this project on a campus may not be generating the application itself, but spreading awareness. This can be accomplished through local media and by incorporating mobile application training into campus Basic Life Support and
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Advanced Cardiovascular Life Support courses. Additionally, it would be advantageous for all incoming students to receive AED and application information at student orientations and for periodic updates to be emailed to faculty, students, and staff. The project is designed to quickly assist users in the event of a SCA emergency to locate an AED after calling 911. Time is the key factor. Users must be familiar with the application and how to use it before an emergency occurs. Finally, the last challenge is to ensure that the map is updated with accurate information as more AEDs are added or removed. Although cardiac arrest events on college campuses are rare, they do exist and with devastating consequences. Recognizing a deficiency in campus AEDs or CPR training before such an event occurs is critical. It is unclear if a specific system is in place to determine where AED units are needed or who is notified when they are installed. The project uncovered an incomplete First Responder’s AED master list. The placement of AEDs also appears random. By mapping these units, further analysis of traffic patterns and population densities could aid in future AED placement. A university policy should also be in place so that whenever an AED unit is added, a master list is updated and all stakeholders are notified by email. Maintaining an up-to-date list will require adequate communication between all stakeholders. With regard to the accuracy of the information in this application, our AED list was drawn from information on file with the First Responders. Additional units discovered while
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ACCEPTED MANUSCRIPT walking the campus were confirmed by emailing both the First Responders and the appropriate building maintenance representatives. Establishing a protocol so that locations could be confirmed and modified (added or removed) every six months or sooner would be beneficial. Crowdsourcing could assist with this process. Lastly, the American Heart Association recommends that AEDs be located no further
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than three minutes from an SCA victim.26 While accomplishing this could be costly, steps can be made to better distribute existing resources or make a case for purchasing more; fundraising and student organizations could assist with this task. Just having AEDs installed is not enough—they need to be easily located. In a time where society increasingly relies on mobile phones to provide information about nearby stores or directions to places in their surroundings, there are opportunities to use mobile technology to locate and share information about relevant emergency devices (e.g. AEDs) in emergency situations.27 Such technology should be incorporated into the chain of survival, and the approach described provides a promising starting point.
Note For comments and further information, address correspondence to Jesse O’Shea, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL 32306-4300, USA (e-mail: [email protected]).
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ACCEPTED MANUSCRIPT References 1. Deo R, Albert C. Sudden cardiac death. Circulation. 2012; 125:620-637. 2. Go A, Mozaffarian D, Roger V, et al. Heart disease and stroke statistics--2014 update: A report from the American Heart Association. Circulation. 2014; 21;129(3):e28-e292. 3. Breastcancer.org. U.S. Breast Cancer Statistics. Available at:
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http://www.breastcancer.org/symptoms/understand_bc/statistics. Accessed April 12, 2014. 4. Weisfeldt M, Sitlani C, Ornato J, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010; 55(16): 1713-20. 5. Sanna T, La Torre G, de Waure C, et al. Cardiopulmonary resuscitation alone vs. cardiopulmonary resuscitation plus automated external defibrillator use by nonhealthcare professionals: a meta-analysis on 1583 cases of out-of-hospital cardiac arrest. Resuscitation. 2008; 76(2): 226-232. 6. Lotfi K, White L, Rea T, et al. Cardiac arrest in schools. Circulation. 2007; 116: 1374– 1379. 7. Harmon K, Asif I, Klossner D, et al. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation. 2011; 123(15): 1594-600. 8. Halabchi F, Seif-Barghi T, Mazaheri R. Sudden cardiac death in young athletes; a literature review and special considerations in Asia. Asian J Sports Med. 2011; 2(1): 1-15.
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ACCEPTED MANUSCRIPT 9. Hazinski M, Markenson D, Neish S, et al. Response to cardiac arrest and selected lifethreatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004; 109: 278–291. 10. Davis R. The goal: “Heart-safe” schools. Available at:
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http://www.usatoday.com/news/health/2006-11-28-aed-schools_x.htm. Accessed May 3, 2013. 11. Garza M. An AED in every school: the next step for public access defibrillation. J Emerg Med Serv. 2003; 28: 22–23. 12. Parent Heart Watch. Action and advocacy. Available at: http://parentheartwatch.org/ActionAdvocacy.aspx. Accessed May 3, 2013. 13. Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public Law 107-188, HR 3448, 107th Congress (2002). 14. National Conference of State Legislatures. State laws on heart attacks, cardiac arrest and defibrillators: encouraging community access and use. Available at: http://www.ncsl.org/programs/health/aed.htm. Accessed May 3, 2013. 15. Stephen Ceasar. iPhone app used to help revive youth basketball player. Available at http://www.latimes.com/news/local/la-me-iphone-cpr-20101203,0,487379.story. Accessed May 3, 2013. 16. NG9-1-1 Project – What is NG9-1-1. National Emergency Number Association. Available at http://www.nena.org/sites/default/files/NG9-11%20Definition%20Final%201.1.pdf. Accessed May 3, 2013.
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ACCEPTED MANUSCRIPT 17. Sakai T, Iwami T, Kitamura T, et al. Effectiveness of the new 'Mobile AED Map' to find and retrieve an AED: A randomized controlled trial. Resuscitation. 2011; 82(1): 6973. 18. Afridi A. Crowdsourcing in Mobile- A Three Stage Context Based Process. IEEE Ninth International Conference on Dependable, Autonomic and Secure Computing. 2011;
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Sydney, Australia. 19. Radboud University Nijmegen Medical Centre. AED 4EU. Available at http://www.aed4.eu/. Accessed May 3, 2013. 20. Merchant R, Asch D, Hershey J, et al. A crowdsourcing innovation challenge to locate and map automated external defibrillators. Circ Cardiovasc Qual Outcomes. 2013; 6: 229-236. 21. Georgia Tech. AED Map. Available at: http://www.ehs.gatech.edu/aed/. Accessed May 3, 2013. 22. Google. Google Maps for Mobile. Available at: http://www.google.com/mobile/maps/. Accessed May 3, 2013. 23. Florida State University. FSU Mobile. Available at: http://its.fsu.edu/Web-Services/FSU-Mobile. Accessed May 3, 2013. 24. Florida State University. About Florida State. Available at: http://www.fsu.edu/about/students.html. Accessed August 10, 2013. 25. Heart & Stroke Foundation. Public Access to Automated External Defibrillators (AEDs). Available at: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3799199/. Accessed December 4, 2013.
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ACCEPTED MANUSCRIPT 26. Aufderheide T, Hazinski M, Kerber R, et al. AHA policy recommendations: Community lay rescuer automated external defibrillation programs. Circulation. 2006; 113: 12601270. 27. Merchant R, Asch D. Can you find an AED if a life depends on it? Circ Cardiovasc Qual
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Outcomes. 2012; 5(2): 241-243.
Received: 11 December 2013 Revised: 16 June 2014 Accepted: 11 July 2014
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Figure 1: Incorporating myFSU mobile into the chain of survival. Illustration Credit: Jodi Slade. © The Florida State University College of Medicine. Reproduction by permission of The Florida State University College of Medicine. Permission to reuse must be obtained from the rightsholder.
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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a Novel Approach for Increasing Accessibility a
a
Ryan Berger & Jesse O’Shea a
Florida State University College of Medicine, Tallahassee Florida Accepted author version posted online: 13 Aug 2014.
To cite this article: Ryan Berger & Jesse O’Shea (2014): AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a Novel Approach for Increasing Accessibility, Journal of American College Health, DOI: 10.1080/07448481.2014.947993 To link to this article: http://dx.doi.org/10.1080/07448481.2014.947993
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
ACCEPTED MANUSCRIPT
Viewpoint AEDs at Your Fingertips: Automated External Defibrillators on College Campuses and a
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Novel Approach for Increasing Accessibility
Ryan Berger1; Jesse O’Shea1 1
Florida State University College of Medicine, Tallahassee Florida
The authors contributed equally to this work
1
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Abstract. The use of AEDs increases survival in cardiac arrest events. Due to the success of previous efforts and free, readily available mobile mapping software, the discussion is to emphasize the importance of the use of AEDs to prevent SCA-related deaths on college campuses and abroad, while suggesting a novel approach to aiding in access and awareness
Downloaded by [University of Regina] at 23:59 04 September 2014
issues. A user-friendly mobile application (a low cost iOS map) was developed at Florida State University to decrease AED retrieval distance and time. The development of mobile AED maps is feasible for a variety of universities and other entities with the potential to save lives. Just having AEDs installed is not enough—they need to be easily locatable. In a time where society increasingly relies on phones to provide information, there are opportunities to use mobile technology to locate and share information about relevant emergency devices and should be incorporated into the chain of survival.
Keywords: automated external defibrillator, cardiopulmonary resuscitation, college health, mobile health, sudden cardiac arrest
2
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ACCEPTED MANUSCRIPT Background A major issue in public health is sudden cardiac arrest (SCA). While sudden cardiac events are more common with increasing age, when experienced in younger populations they are often more deadly.1 Over 424,000 people experience emergency medical services (EMS)assessed out-of-hospital non-traumatic sudden cardiac arrest yearly and nine out of ten victims
Downloaded by [University of Regina] at 23:59 04 September 2014
die.2 To put this into perspective, sudden cardiac death accounts for nearly ten times the number of individuals who die from breast cancer annually.3 Sudden cardiac arrest is a pulseless condition that occurs when the heart ceases to pump blood effectively or at all. When blood is no longer circulating in the body, the individual collapses and is considered clinically dead. A substantial obstacle in treating victims of SCA is time. Fortunately, as automated external defibrillators (AED) have become easier to use and more available, survival following SCA has subsequently improved. In one study, 11.4% of EMS-treated non-traumatic SCA victims survived. Comparatively, if treated with bystander cardiopulmonary resuscitation (CPR) and an AED before EMS arrival, survival rates climbed to 38%.4 A recent meta-analysis concluded that programs based on CPR plus early AED defibrillation by trained non-healthcare professionals offer a survival advantage over CPR alone.5 However, the effectiveness of an AED device depends on it being present or immediately delivered to the site of arrest. Regardless of their life saving potential, AEDs are of no value if they cannot be located and utilized effectively. Imagine a student, unconscious and without a pulse. A bystander immediately starts resuscitation efforts and EMS is en route; however, neither are aware that there is an AED less than 50 feet away in a nearby classroom.
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ACCEPTED MANUSCRIPT When compared to lower-level schools (preschool, elementary, middle) and high schools, colleges have the highest incidence rate of SCA.6 Between 1990 and 2005, the estimated annual incidence of SCA events in lower-level schools and colleges was 0.18 per 100,000 person-years among students and 4.51 per 100,000 person-years for school faculty and staff.6 More alarming, SCA in National Collegiate Athletic Association (NCAA) student-athletes is the leading cause of
Downloaded by [University of Regina] at 23:59 04 September 2014
death, claiming one life per 22,903 participants in the 17-24 age range—up to seven times higher than previously predicted.7 While data on adult SCA is plentiful, current studies exposing the full scope of sudden cardiac arrest events in younger populations is lacking. Furthermore, routine sports physicals fail to detect many of the conditions that cause SCA in young adults; such as hypertrophic cardiomyopathy, valvular disease, and electrical disorders.8 Student deaths from SCA can trigger deep emotions among family and community members and raise concerns about the vulnerability of other school-age individuals. Such events have increased awareness of school-based rescue actions that include SCA recognition and emergency activation, early CPR, early defibrillation, and timely advanced care. Collectively, these actions are termed “links in the chain of survival”. These incidents have led numerous groups to advocate for AEDs in every school.9-12 Advocacy efforts have prompted legislation in several states requiring AED placement in schools, as well as a US congressional bill promoting access to defibrillators on school grounds.11-14 Recently, the media has featured several stories of individuals successfully using content on their mobile phones to save lives.15 Mobile phones allow responders to attend to victims during emergencies while simultaneously contacting emergency services. A recent study indicated a nearly six fold increase in the use of mobile phones for contacting EMS providers; an
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ACCEPTED MANUSCRIPT increase which appreciably decreased the time required to notify emergency45 providers of an incident.16 In 2009, researchers first developed a mobile AED mapping system in Japan. AED locations were mapped using information from Japan’s Public Access Defibrillation Program. Using a cell phone’s GPS, the application triangulated the user’s location and displayed a map of
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the nearest AEDs and their distances from the caller; names, business hours, and telephone numbers of the facilities were also displayed. A control group and a group with the mobile phone application were placed throughout Kyoto University and given a simulated SCA event. The study found that the group with the phone application traveled a significantly shorter distance (from victim location to AED) than the control group. However, the time for AED retrieval was not appreciably diminished. The researchers attributed this to the time needed to operate the application and limited cell phone data speeds. Also, participants were trained to use the system just prior to the experiment. The researchers suggested that a navigation system with a digital compass or a one-touch operation system may shorten the time of AED retrieval.17 “Crowdsourcing”, or “tapping the power of a crowd,” is a relatively new term with broad applications.18 By applying crowdsourcing to healthcare, patients are empowered with the tools needed to take charge of their own healthcare. An example of this technology is the AED4U program in the Netherlands, which consists of a website and mobile phone application where users, via their smart phones, can access, input, and share the locations of AEDs. 19 American universities have yet to take advantage of this mobile-friendly technology. Recently, a project called the “MyHeartMap Challenge” was implemented in Philadelphia. The project encouraged individuals to photograph, collect, and submit, either online or through a mobile application,
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ACCEPTED MANUSCRIPT supplemental information about AEDs users identified in the city. Participation was further incentivized with monetary prizes. The study resulted in the submission of 1,429 AED locations, 852 of which were unique, nonoverlapping, and confirmed as valid.20 The “MyHeartMap Challenge” demonstrated the effectiveness and potential of crowdsourcing for such tasks. Until recently, Florida State University (FSU), located in Tallahassee, Florida, lacked a
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physical or online map of campus AEDs. Other universities have already taken advantage of online technology use to map out AEDs, including the Georgia Institute of Technology.21 For example, Google provides free custom-mapping software, including step-by-step navigation, that is available in a mobile form.22 Building upon previous efforts, this discussion emphasizes the importance of AEDs in preventing SCA-related deaths on college campuses and suggests a novel approach to expand awareness and emergency access. A model application was implemented at Florida State University that was designed to decrease AED retrieval distance and time. This was based on ease of use, low threshold for implementation, low cost, and wide availability. The application was created using an existing mobile platform utilized by FSU and many other institutions. The application allows students, faculty, and visitors to easily identify the locations of AEDs on campus and will likely increase the chances of survival in the event of a SCA emergency. A Novel Approach The FSU AED application was designed to be incorporated into the SCA chain of survival (see Figure 1). After stakeholders were identified, our team was able to secure a list, although outdated and incomplete, of known AEDs from FSU’s First Responders. Stakeholders included the FSU Police Department, First Responders, building managers, and information
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ACCEPTED MANUSCRIPT technology services. The list was then used to locate, record, and photograph the AEDs and also to obtain their coordinates using Google Maps. A description of the AED’s location and a contact number was also documented. The locations of any damaged, inaccessible, or newly located AEDs were shared with First Responders. Once this list was compiled, our team contacted the FSU Office of Information
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Technology Services in order to incorporate the AED locations into the ‘Places’ section of the existing myFSU Mobile application. The existing application is Blackboard Mobile Central, which many universities already use, including FSU, Stanford, and Loyola. Any school using this platform may utilize this technology. Data obtained from the mobile devices was then entered into a .CSV file and uploaded onto the server. Once entered, the data was immediately live and automatically accessible to everyone with the myFSU Mobile application. With regard to updating the data, any changes made are reflected on the same day, as the server refreshes the data every six hours. From initial idea to live product, this project took approximately three months to complete. Physical data was gathered over a three day period by walking the FSU campus. Data entry into myFSU Mobile took two days. Identifying and corresponding with stakeholders required significant time due to the bureaucracy of a large university, the ambiguity surrounding stakeholders, permission granting, and difficulty scheduling with multiple parties. However, all parties involved were extremely helpful and optimistic in working to make FSU’s AEDs more accessible and transparent.
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ACCEPTED MANUSCRIPT The Outcome By clicking on the myFSU Mobile application, users can quickly access the list of campus AEDs. By clicking on an AED location, the user can access more detail, including a simple description of the unit’s location, approximate walking distance and time (from current location), map, and photograph. The user can also see the relationship of the unit to the campus
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at large, as well as their current location via GPS. The Augmented Reality mode automatically enables the user’s smartphone camera. Augmented Reality is an innovative new technology which leverages the iPhone’s camera and GPS to identify surrounding buildings in a 3D, interactive view. As the user scans their environment, the AED they are looking for is automatically overlaid in their visual field when they are pointed in the right direction, including the name of the AED unit and its approximate distance from the user’s current location. When viewing a map of all campus AEDs in Augmented Reality, the closest AEDs appear the largest. This application can be further explored by downloading the free application from the ‘App Store’. The Impact This project resulted in cataloging all known FSU main campus AEDs. Thirty-eight AED units were integrated into one mobile map accessible to more than 61,000 Apple iOS users and over 118,000 total active users of myFSU Mobile.23 The AED addition to myFSU Mobile will directly impact over 40,000 students enrolled at FSU’s main campus, as well as thousands more employees and visitors.24 Indirectly, this project created a greater awareness of CPR, AEDs, and SCA at FSU. This was accomplished by word-of-mouth and through publicity surrounding the project, such as local radio, news stations, and university press. However, there is no way to
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ACCEPTED MANUSCRIPT determine how effective these advertising channels were, and knowledge of campus AED units and cardiac arrest was not assessed prior to this project. This could be a goal of future implementations at other institutions. Moving Forward Sudden cardiac arrest in the college setting is a reality that must be adequately addressed.
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Recent studies have suggested that SCA in this population may be grossly underestimated, especially in regard to student athletes.7 Although heart disease is generally associated with advanced age, there are still at-risk individuals in younger populations, and college students have the highest incidence of SCA events when compared with children in grades K-12.6 This project demonstrates that the development of mobile AED maps is feasible for a wide variety of school districts, universities, businesses, and governmental entities with the potential to save lives. The Heart and Stroke Foundation of Canada made four key recommendations to the general public regarding public access to AEDs.25 These include (1) having widespread access to AEDs, especially in settings where SCA is of higher probability, (2) being trained and encouraged to use CPR and AEDs in a SCA event, (3) ensuring that targeted responders are adequately trained, equipped, and directed to use AEDs, and (4) registering AEDs with the appropriate authorities to ensure visibility and maintenance. The authors support these recommendations and suggest adopting mobile AED technology, similar to the project at FSU, to assist in reaching these goals. For schools that already utilize Blackboard Mobile Central, implementing an AED application is feasible and virtually cost-free. Currently, the ‘Places’ feature is only available on the Apple mobile operating system ‘iOS’ platform, so expanding this to other platforms would
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ACCEPTED MANUSCRIPT empower more users with this feature. However, for smaller campuses or those lacking this resource, a web-based version of an AED map would be a step in the right direction. The most important challenge in implementing this project on a campus may not be generating the application itself, but spreading awareness. This can be accomplished through local media and by incorporating mobile application training into campus Basic Life Support and
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Advanced Cardiovascular Life Support courses. Additionally, it would be advantageous for all incoming students to receive AED and application information at student orientations and for periodic updates to be emailed to faculty, students, and staff. The project is designed to quickly assist users in the event of a SCA emergency to locate an AED after calling 911. Time is the key factor. Users must be familiar with the application and how to use it before an emergency occurs. Finally, the last challenge is to ensure that the map is updated with accurate information as more AEDs are added or removed. Although cardiac arrest events on college campuses are rare, they do exist and with devastating consequences. Recognizing a deficiency in campus AEDs or CPR training before such an event occurs is critical. It is unclear if a specific system is in place to determine where AED units are needed or who is notified when they are installed. The project uncovered an incomplete First Responder’s AED master list. The placement of AEDs also appears random. By mapping these units, further analysis of traffic patterns and population densities could aid in future AED placement. A university policy should also be in place so that whenever an AED unit is added, a master list is updated and all stakeholders are notified by email. Maintaining an up-to-date list will require adequate communication between all stakeholders. With regard to the accuracy of the information in this application, our AED list was drawn from information on file with the First Responders. Additional units discovered while
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ACCEPTED MANUSCRIPT walking the campus were confirmed by emailing both the First Responders and the appropriate building maintenance representatives. Establishing a protocol so that locations could be confirmed and modified (added or removed) every six months or sooner would be beneficial. Crowdsourcing could assist with this process. Lastly, the American Heart Association recommends that AEDs be located no further
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than three minutes from an SCA victim.26 While accomplishing this could be costly, steps can be made to better distribute existing resources or make a case for purchasing more; fundraising and student organizations could assist with this task. Just having AEDs installed is not enough—they need to be easily located. In a time where society increasingly relies on mobile phones to provide information about nearby stores or directions to places in their surroundings, there are opportunities to use mobile technology to locate and share information about relevant emergency devices (e.g. AEDs) in emergency situations.27 Such technology should be incorporated into the chain of survival, and the approach described provides a promising starting point.
Note For comments and further information, address correspondence to Jesse O’Shea, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL 32306-4300, USA (e-mail: [email protected]).
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ACCEPTED MANUSCRIPT References 1. Deo R, Albert C. Sudden cardiac death. Circulation. 2012; 125:620-637. 2. Go A, Mozaffarian D, Roger V, et al. Heart disease and stroke statistics--2014 update: A report from the American Heart Association. Circulation. 2014; 21;129(3):e28-e292. 3. Breastcancer.org. U.S. Breast Cancer Statistics. Available at:
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http://www.breastcancer.org/symptoms/understand_bc/statistics. Accessed April 12, 2014. 4. Weisfeldt M, Sitlani C, Ornato J, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010; 55(16): 1713-20. 5. Sanna T, La Torre G, de Waure C, et al. Cardiopulmonary resuscitation alone vs. cardiopulmonary resuscitation plus automated external defibrillator use by nonhealthcare professionals: a meta-analysis on 1583 cases of out-of-hospital cardiac arrest. Resuscitation. 2008; 76(2): 226-232. 6. Lotfi K, White L, Rea T, et al. Cardiac arrest in schools. Circulation. 2007; 116: 1374– 1379. 7. Harmon K, Asif I, Klossner D, et al. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation. 2011; 123(15): 1594-600. 8. Halabchi F, Seif-Barghi T, Mazaheri R. Sudden cardiac death in young athletes; a literature review and special considerations in Asia. Asian J Sports Med. 2011; 2(1): 1-15.
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ACCEPTED MANUSCRIPT 9. Hazinski M, Markenson D, Neish S, et al. Response to cardiac arrest and selected lifethreatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004; 109: 278–291. 10. Davis R. The goal: “Heart-safe” schools. Available at:
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http://www.usatoday.com/news/health/2006-11-28-aed-schools_x.htm. Accessed May 3, 2013. 11. Garza M. An AED in every school: the next step for public access defibrillation. J Emerg Med Serv. 2003; 28: 22–23. 12. Parent Heart Watch. Action and advocacy. Available at: http://parentheartwatch.org/ActionAdvocacy.aspx. Accessed May 3, 2013. 13. Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public Law 107-188, HR 3448, 107th Congress (2002). 14. National Conference of State Legislatures. State laws on heart attacks, cardiac arrest and defibrillators: encouraging community access and use. Available at: http://www.ncsl.org/programs/health/aed.htm. Accessed May 3, 2013. 15. Stephen Ceasar. iPhone app used to help revive youth basketball player. Available at http://www.latimes.com/news/local/la-me-iphone-cpr-20101203,0,487379.story. Accessed May 3, 2013. 16. NG9-1-1 Project – What is NG9-1-1. National Emergency Number Association. Available at http://www.nena.org/sites/default/files/NG9-11%20Definition%20Final%201.1.pdf. Accessed May 3, 2013.
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ACCEPTED MANUSCRIPT 17. Sakai T, Iwami T, Kitamura T, et al. Effectiveness of the new 'Mobile AED Map' to find and retrieve an AED: A randomized controlled trial. Resuscitation. 2011; 82(1): 6973. 18. Afridi A. Crowdsourcing in Mobile- A Three Stage Context Based Process. IEEE Ninth International Conference on Dependable, Autonomic and Secure Computing. 2011;
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Sydney, Australia. 19. Radboud University Nijmegen Medical Centre. AED 4EU. Available at http://www.aed4.eu/. Accessed May 3, 2013. 20. Merchant R, Asch D, Hershey J, et al. A crowdsourcing innovation challenge to locate and map automated external defibrillators. Circ Cardiovasc Qual Outcomes. 2013; 6: 229-236. 21. Georgia Tech. AED Map. Available at: http://www.ehs.gatech.edu/aed/. Accessed May 3, 2013. 22. Google. Google Maps for Mobile. Available at: http://www.google.com/mobile/maps/. Accessed May 3, 2013. 23. Florida State University. FSU Mobile. Available at: http://its.fsu.edu/Web-Services/FSU-Mobile. Accessed May 3, 2013. 24. Florida State University. About Florida State. Available at: http://www.fsu.edu/about/students.html. Accessed August 10, 2013. 25. Heart & Stroke Foundation. Public Access to Automated External Defibrillators (AEDs). Available at: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3799199/. Accessed December 4, 2013.
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ACCEPTED MANUSCRIPT 26. Aufderheide T, Hazinski M, Kerber R, et al. AHA policy recommendations: Community lay rescuer automated external defibrillation programs. Circulation. 2006; 113: 12601270. 27. Merchant R, Asch D. Can you find an AED if a life depends on it? Circ Cardiovasc Qual
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Outcomes. 2012; 5(2): 241-243.
Received: 11 December 2013 Revised: 16 June 2014 Accepted: 11 July 2014
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Figure 1: Incorporating myFSU mobile into the chain of survival. Illustration Credit: Jodi Slade. © The Florida State University College of Medicine. Reproduction by permission of The Florida State University College of Medicine. Permission to reuse must be obtained from the rightsholder.
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