Mayr, N. Patrick MD; Mayr, Tanja MD; Tassani, Peter MD; Martin, Klaus MD
From the Institut für Anästhesiologie, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
Address correspondence to: N. Patrick Mayr, MD, Institut für Anästhesieologie, Deutsches Herzzentrum München, des Freistaates Bayern, Technische Universität München, Lazarettstr. 36, D-80636 Munich, Germany (firstname.lastname@example.org).
Dr NP Mayr received a research funding (KKF-Proj. 4.1–09) for this study from the Ministry of Science, State of Bavaria.
The authors declare no conflict of interest.
Objective: Automated external defibrillators (AEDs) are widely used to increase survival of patients with sudden cardiac arrest (SCA). Despite these experiences only few data exist dealing with SCA at the workplace or AED usage in the occupational setting.
Methods: In a pilot study, occupational physicians throughout Germany were contacted and queried about the utilization of AED and the primary success rate (return of spontaneous circulation; ROSC).
Results: Of 232 occupational physicians, 155 (67%) stated that the enterprise provided at least one AED. Overall, 63 AED utilizations were analyzed. An ROSC was reported in 42 patients (67%). In 48% (n = 20) ROSC was established before the arrival of the EMS.
Conclusion: Our study showed a high proportion of patients with ROSC after SCA. Increased attention should be turned to workplace SCA and AED programs.
Sudden cardiac arrest (SCA) is one of the most time-dependent emergencies in prehospital care and usually associated with poor prognosis.1 Early basic life support and early defibrillation have shown to be the most effective therapies for these patients and intense efforts have been undertaken to raise the chance of survival for these patients. Early defibrillation programs were initially started in emergency medical service (EMS) systems and successive public access defibrillation (PAD) programs were implemented in establishments with high foot traffic such as public transport stations, airports, and shopping centers.2–4 In 2001, the German Federal Medical Association issued their first guidelines for the use of automated external defibrillators (AEDs) in a “nonmedical” setting like the use by company first responders. Nowadays, ideas like the French “4 Minutes”5 or the Dutch “6minutenzone”6 programs try to shorten the therapy-free interval to a minimum. In the United States, three federal initiatives (“Cardiac Arrest Survival Act,”7 “Guidelines for Public Access Defibrillation in Federal Facilities,”8 and “Emergency Medical Equipment, Final Rule”9 are supporting the usage of AEDs in federal facilities, other public buildings and aircrafts.
The American Heart Association and European Resuscitation Council guidelines recommend the provision of a PAD program in areas with at least one cardiac arrest every 2 years.
In addition, the American Heart Association recommends the provision of an AED in places where more than 250 people (older than 50 years) are present over a period of 16 hours a day.10 The growing obsolescence of Western societies demands employees to work to a higher age. As Europe's largest and the world's fifth largest economy, the Federal Republic of Germany is especially affected by this demographic situation. Official estimations from the German Federal Ministry of Labour assume that in 2015 every third employee will be aged 50 years or older. Globalization, economic crisis, reduction of employees, and new technologies are only some causes leading to a densification of the daily workload. In Japan, dying at the workplace due to continuous overwork (“Karoshi“) has been accepted as “occupational death.”11,12 Approximately 150 persons seem to die from “Karoshi” every year at their place of work. The US Occupational Safety and Health Administration (OSHA) estimates that 15% of all workplace fatalities are caused by SCA (approximately 400 per year) and supports the use of AED at the workplace.13
In 2006, the American College of Occupational and Environmental Medicine (ACOEM) reaffirmed its 2001 published guidelines for the implementation of occupational AED programs.14 Yet there are only a few publications dealing with cardiac arrest or the use of AED in the workplace, and to the best of the authors' knowledge there is no structured analysis available dealing with the workplace use of AEDs in Germany.
This study was designed as a pilot study. A questionnaire on workplace emergencies and the utilization of AEDs was developed in cooperation with an occupational physician. This questionnaire was designed to capture AED provision, utilization, and primary success rate since the implementation of the enterprises AED program. The autors asked for all AED utilizations since the program implementation. Automated external defibrillator utilization was defined as activating the AED in an unconscious person with cardiac arrest. Primary success was defined as return of spontaneous circulation (ROSC) either before or after the arrival of the local public EMS. In addition, we asked for information about the company's number of employees and the company's internal emergency system.
Generally accepted classifications for enterprise size do not exist. Most enterprises did not want to report the exact number of employees. In addition, there are often contract workers or employees sent by ancillary companies present in the enterprises. These employees and their number are mostly unknown to the enterprises' own occupational physicians. On the basis of the recommendation of the European Commission, responding enterprises were classified in three groups: “small enterprise”—less than 50 employees; “medium-sized enterprise”—less than 250 employees; and “large-sized enterprise”—more than 250 employees.15 An enquiry representative to Germany's economy was considered impracticable. So the authors chose occupational physicians that were listed in the public area of the State Chambers of Physician's Internet presence or as publicly listed member of the Alliance of German Occupational Physicians. Occupational physicians not active in enterprises (eg, academic institutions, Employer's Liability Insurance Association, hospitals) were excluded. In case of listing of more than one occupational physician for one enterprise location, only the executive occupational physician was chosen. To avoid cross-company bias, small medical offices or companies providing occupational physician services for more than one enterprise were also excluded. Physicians providing only private contact addresses were also excluded. Each contacted occupational physician was responsible for one enterprise. The occupational physicians were initially contacted by telephone. After their agreement to participate, the questionnaire was sent to them by mail or e-mail. A reminder e-mail or telephone call was initiated after 4 weeks. Nonresponding physicians were excluded after a total of 8 weeks.
In 2009, a total of 2762 board-certified occupational physicians and additional 5308 physicians with a qualification in occupational medicine were listed in the German Federal Medical Association. A total of 1400 available addresses from occupational physicians were screened for eligibility; 52% (n = 588) of these occupational physicians were working in small doctor's offices or only a private contact address was available; 26% (n = 294) served in companies providing interplant occupational health services. Academic institutions, Employer's Liability Insurance Association, or hospitals employed 18% (n = 204). In a further 4% (n = 45), multiple occupational physicians were named in the enterprises. Finally, 269 (19%) occupational physicians were considered eligible and over a period of 8 months initially contacted. One hundred ninety-one occupational physicians agreed to participate and were included. Within 8 weeks after the first contact, the authors received 110 questionnaires (response rate 58%). Numerous occupational physicians distributed the questionnaire unasked to colleagues. In total, we received a total of 232 filled questionnaires.
Most responses came from large-sized enterprises (65%) occupying more than 250 employees; 16% of the responding occupational physicians attended small enterprises with up to 50 employees.
One hundred fifty-five (67%) of the occupational physicians stated that the enterprise provided at least one AED (Table 1). Additional manual defibrillators for physician use were present in 67 (43%) of these enterprises. Thirteen (6%) of the occupational physicians provided only a manual defibrillator for physician emergency use.
Automated external defibrillators were predominantly provided nearby professional users like the occupational physicians or company's first responders (60%), the company's gates (41%), or plant fire department (30%). Other “typical” areas for AED provision like the production line (17%), areas of high foot traffic (13%), or the staff canteen (3%) were underrepresented. Only two (1%) companies provided AEDs solely as a PAD system. Seven companies (5%) provided a dual system of PAD and professional-based early defibrillation (occupational physicians, first responder). The vast majority (94%, n = 148) preferred a solely professional-based early defibrillation system.
A “workplace AED program protocol” as recommended by the ACOEM guidelines was present in 59% (n = 91); however, these protocols were open to the employees in 60 companies (39%) only.
Forty-two enterprises (27%) reported at least one AED utilization and 17 of these more than one. Overall, the occupational physicians reported 66 AED utilizations. Details are shown in Table 1. All AED utilizations were done in large-sized enterprises. Three questionnaires did not contain information about ROSC. Therefore, 63 questionnaires were analyzed. An ROSC was reported in 42 patients (67%). In 20 patients (48%), the occupational physicians reported the establishment of an ROSC before the arrival of the local public EMS system. In a further 11 patients (26%), ROSC was established after the EMS arrival. In the remaining 11 patients (26%), occupational physicians reported an ROSC on the scene but did not specify the point of time. Twenty-six (68%) of the occupational physicians reporting an AED use stated that they were present daily during working hours. Twenty-four (63%) of these reported involvement in the company's emergency care. The exact placement of the used AED could not be retrieved. The AEDs in this group were predominantly provided nearby professional first aid teams. Seventy-four percent were placed at the plant fire department or other emergency cars, 42% with the company's first responders, and 24% in the occupational physician's office. In 50%, an AED was placed at the company's gate or the plant security.
Prehospital SCA is associated with poor prognosis worsening every minute without proper first aid.16,17 In our pilot study, an ROSC could be established on the scene in 67% of cases and nearly every second ROSC was established before the arrival of the local public EMS.
Publications about SCA at the workplace are very rare and include only information about single areas of EMS operation. A 2005 retrospective analysis published by Descatha et al18 compared 72 SCA occurring at the workplace to 144 SCA outside the workplace in a region near Paris, France. An SCA was witnessed more often at the workplace (65% vs 59%), chest compression was performed more often (36% vs 16%) and ROSC was achieved more often in the “workplace SCA” group (40% vs 28%). 18 Similar data were published by Descatha et al,19 based on a retrospective analysis of Paris Fire Department protocols from 2004. Both analyses were limited to a defined area in Paris. However, Descatha did not provide a description of the urban structure or the enterprise zones. In 2003, ACOEM published a nationwide survey of AED utilization in US enterprises. Seventy-eight percent of the 177 responding companies reported that they provided an AED program. Thirty-four percent of these companies reported AED utilization with an overall primary success rate of 71%.20 To the best of the authors' knowledge, this is the first survey of workplace AED programs not limited to EMS areas of operation in Germany and this study's results seem to be comparable to those shown in other countries. German federal law obligates the companies to provide first aid-trained employees for in-company emergencies and these first responders are obliged to renew their first aid knowledge every 2 years. Companies are also obliged to develop a plan for in-company emergencies and name the responsible first responders to provide qualified first aid before EMS arrival. The authors' data suggests that expanding an existing in-company emergency system with an AED program is beneficial. Two thirds of all employees suffering an SCA at the workplace gained ROSC and nearly every second one solely by the use of an AED. Using the yearly statistics of 400 SCA fatalities in the United States and 150 “Karoshi” fatalities in Japan, widespread workplace AED programs could lead to an ROSC at the workplace in 268 US and 100 Japanese employees every year. The combination of more witnessed SCA, a company emergency plan, regularly trained first responders, and AEDs could raise the chance of survival after SCA in the workplace.
This study was designed as a pilot study. Like in the other mentioned trials, the authors gained retrospective data. Therefore, no information about the first SCA cardiac rhythm in patients without ROSC was available. As this was a pilot study, the authors did not gain long-term information about the surviving patients and their reintegration into working life.
Despite the fact that AEDs have been in use in the German public EMS for decades with good results, the Employer's Liability Insurance Association recommended workplace AED programs for the first time in 2010. This study showed a high proportion of patients with ROSC after SCA. In the authors' opinion, increased attention should be turned to workplace SCA and the implementation of workplace AED programs. Fighting workplace SCA is an interdisciplinary task. National Occupational Medicine and Emergency Medicine Societies should work hand in hand to enhance workplace AED programs. A nationwide prospective interdisciplinary registry could be reasonable to identify the in-company areas of a higher incident of SCA. Not only the proportion of ROSC (as in this study) but also the proportion of long-term survivors and even more so the proportion of employees returning to their workplace could show the potential benefit of a workplace AED program.
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