From Point A to Point B to Point D
Strategies to rapidly and reliably deliver your AED
By Richard M. Obertots, MBA

"The code of competence is the only system of morality on a gold standard." Ayn Rand, Atlas Shrugged

Why should we strive for competence in delivering AEDs as a gold standard? Perhaps it is best stated in the NCED's positioning slogan, "Because so many more can survive." Many variables affect the survival probability for each person who experiences sudden cardiac arrest (SCA). One of the most important variables is how rapidly and reliably the AED device is physically delivered to the victim's side. Here are some principles to contemplate and actions to take as you strive to help more survive.

Rapid and reliable delivery is mission critical
Yes, it can be a daunting effort to plan, implement, manage and continually improve a PAD (Public Access Defibrillation) program. After many hours, many tasks, many meetings and often significant financial investment to acquire the equipment and complete basic AED operation training, the detailed preparation to enable the rapid and reliable delivery of the device is often a low priority. Many times it is only a marginal consideration.

(1) To truly achieve early defibrillation, aspects that relate to the rapid and reliable delivery of the device must be considered mission critical! Few life threatening medical emergencies are as time sensitive as SCA. Considering the rapid and reliable delivery of the device as an anchor point of your PAD program and having a mind set that makes this just as important as knowing how to operate the device or perform CPR will significantly increase the likelihood that more can survive.

A systems approach: Do the dynamics
Complexity science advocates that systems are dynamic and seek to self-organize. Those of us who have been involved in more resuscitation efforts than we can recall know that each defibrillator delivery creates its own set of unique and often unpredictable circumstances. The tendency seems to be more toward chaos as we seek to manage each step to transport the AED to enable it to work to achieve an organized cardiac rhythm. Delivering the equipment can often find us in a hyper-dynamic state. If our AED delivery planning uses a static approach, that is, we do not factor for a set of PTIs (Probable Transport Impediments), we will greatly diminish our chances of success. Here are a few examples of variables that we use in our FMECA (Failure Mode Effects & Criticality Analysis) model that you should consider. (2)

On-property AEDs

For PAD programs in which AEDs are located within the facility or on the site:

What primary mode of transport will be used? Remember, based on the location of the victim, the AED and dynamic condition, it may be necessary to use more than one primary mode of transport to accomplish the most rapid and reliable AED delivery. Each will affect the speed of delivery. Each needs to be factored. Keep in mind conditions may exist on your property that make a slower mode of transport more reliable.

Mode of transport possibilities
- Rapid walking
- Running
- Roller blades
- Scooter (motorized/human powered)
- Bicycle
- Snow skis / Snow board
- Snow mobile
- Motorcycle
- Hovercraft
- Electric cart or fossil fuel powered (golf cart)
- Water vehicle
- Elevator
- Escalator
- Tram
- Rail vehicle
- Horse (Animal)
- All terrain vehicle (three or four wheeler)
- Car/ van/ truck /tractor
- Other______________________

What conditions and dynamics may exist to impede these modes of transport?

- Barriers
- Confined space
- Steep terrain
- Multiple floors
- Mass exodus/crowding i
- Controlled access/locked doors
- Unpaved/uneven surfaces
- Situation that could block passageways (access/egress)
- Situation that could block the most direct route
- Situation that could block the next most direct route
- Environmental/seasonal conditions / weather
- Areas of construction /renovation /HAZMAT that must be bypassed
- Secure area(s) (presidential /foreign dignitary /celebrity)
- More that one simultaneous emergency response on your property
- Poor visibility/darkness
- Other_______________________

Off-property AEDs

For PAD programs in which the AED is being transported to your location by EMS, fire, police, rescue, ski patrol, Coast Guard, gated community security, etc.:

What conditions and dynamics may exist to impede the AED delivery to your location?
- Traffic (times of day /year /special events)
- Distance
- Terrain
- Limited response vehicles, that is, resources being used for another response (Contrary to what many believe - emergency response vehicles and personnel are not sitting 24/7 "on station" waiting for your call. From large urban systems to small remote communities, many scenarios can occur to completely overwhelm resources. You are well advised to learn about your primary off-property response "Mutual Aid" agreements.3
- Limited response personnel (Those responsible for delivering an AED to your property may be subject to a wide variety of availability and scheduling of personnel. Staffing or vehicles may be cut significantly for afternoon or midnight shifts. Also, seasonality can greatly affect round-the-clock staffing.)
- Union actions (Your off-property response organization may be on strike.)
- Volunteer response organization (To their credit, volunteer emergency / fire services do their best to have people available around the clock. It's not easy. If you rely solely on this kind of AED delivery mode, keep abreast of their membership, staffing and response capability. Work with them! Some do have full-time personnel who are reinforced by "on-call" volunteers. Remember, if you are in a one ambulance or AED delivery vehicle town, it may be on a call, out of town on a long distance transport, or out of service for a variety of legitimate reasons.)
- Weather/environment
- Lack of understanding about how to find your location
- Lack of understanding about how to find the best entry point once on your property
- Lack of direct-real-time communications (radio, cell phone)
- Failure to have persons pre-assigned and stationed at the designated entry point(s) to escort the off-property AED delivery personnel. (They may arrive rapidly, only to be impeded by trying to find the victim, by getting delayed in a freight elevator or by being locked in a secure passage way)
- Other_____________________________

Secondary, redundant contingencies

What secondary and redundant contingencies are to be used when the primary mode of transport is not available, impeded or may be vulnerable to being impeded? Remember, reliability is part of the equation. Unique conditions may exist at your site that require Plan B or Plan C to accomplish Plan D (defibrillation.) You may have a state-of-the-art emergency response cart, but if it is being used elsewhere or being serviced, it will be of no use to you in this instance. Back up for back up is key.

FMECA (Failure Mode Effects & Criticality Analysis)

Once you have assessed a variety of PTIs (Probable Transport Impediments) it is important to evaluate two key concerns.

First, what are the ranges of probability that PTIs will occur? One possible taxonomy includes five discriminators. Frequent --> Reasonably Probable --> Occasional --> Remote --> Extremely Remote. Only you know your property and community. And, the situation can change hour by hour. But reliable forecasts can be made with a reasonable amount of think-through. If you know that everybody darts out of the building at the stroke of 5:00 PM, while others are darting in for the next shift you need to assess how this will affect rapid and reliable response. You must account for the fact that your response team may not be available. You also know that the probability that passage ways will be congested with people five days per week between the hours of (x and y). Therefore, the delivery of your AED may be impeded. Your AED delivery plan should factor this so that redundant contingencies are in place.

Second, what are the severity of the consequences should a failure occur? Four failure mode levels can be established: Catastrophic --> Critical --> Marginal --> Minor. Based on the previous scenario of extremely congested passageways - you may evaluate the severity as critical or maybe even catastrophic (depending upon the distance your AED must travel).

Now it's a matter of prioritization and preparation. Once you've established parameters concerning the probability and severity of AED transport impediments, you can anticipate with a reasonable degree of certainty the situations that need your attention. Begin with planning for situations that are Frequent in Probability with a Severity that would be Catastrophic. It is understood that infinite combinations could be devised. What matters is to devote a reasonable effort to prudently prepare for situations that could render your response completely ineffective.

Year round AED delivery dynamics: monitoring and alertness

Andy Grove of INTEL(r) said it best with the title of his classic business book, Only the Paranoid Survive. If we are to try to deliver AEDs more rapidly and reliably "Because so many more can survive(tm)," then we need to remain "paranoid." Each locale has unique dynamics. The situation can change hour by hour, day by day, week by week, month by month and year by year. It's up to each of us to know our operational environment. Just as we can anticipate night and day and the seasons with a reasonable degree of certainty, so we can anticipate and be in synch with the dynamics of our properties. To perform effectively, we must design AED delivery systems that allow for year round dynamics.

Real time and virtual exercises: The thrill of the drill

In most settings, the process of determining how to design and deploy high performance AED delivery systems is in dire need of improvement. Conducting routine real-time and virtual AED delivery exercises is essential. Few actions are as valuable as experience. Despite the logistical complications and perceived costs, those who are truly committed to effective PAD must engage in regular exercises and/or drills to assess performance under a wide variety of scenarios to refine their entire "Chain of Survival" process. It's essential for leaders to promote "The thrill of the drill."

Rapid and reliable AED delivery can be practiced in real-time situations or the process can be simulated in a variety of ways in regularly scheduled group sessions or by individuals simply committing to daily think-through. Things as simple as daily e-mail reminders or start of shift briefings to focus on specific areas of the plan can greatly help to combat "rust-out." All too often, PAD programs are launched with great enthusiasm and intensity. All too soon, they begin to rapidly lose their performance capacity.

Recently, we sent one of our staff to meet with a conference center/golf course client three months after their initial AED program implementation. Although he had felt confident that those who had been trained were competent at the time--just three months later--two of the individuals he asked to perform a spontaneous "drill" had significant problems that delayed the rapid and reliable delivery of a shock. He discovered that the client had not complied with their agreement with our firm to conduct real-time and virtual AED delivery drills according to our schedule and performance standards. The excuse was "It was peak season, we short staffed and too busy." Yes, that's reality. Reality also is that real people who may experience sudden cardiac arrest are relying on us.

A significant challenge is faced by those who desire to be effective at the rapid and reliable delivery of AEDs. The reality is it's a difficult thing to schedule regular and varied drills--actual or virtual. On the other hand, if organizations and communities are going to make the commitments to purchase and deploy AEDs, they must also make commitments to be effective--around the clock, around the calendar. We know we can't save everybody, but we also know that everybody deserves the best possible chance to be saved. Are we to be defibrillation-delusional or defibrillation deliverable?

PAD programs that simply conduct one-time training and one-time (if any) real-time AED delivery exercises will have little chance to gain or sustain proficiency at getting their AEDs from point A to point B to accomplish the ultimate... point D (defibrillation.) As challenging as it may be, planning, paranoia, practice, review of that practice, adapting and modifying processes as a result of practice, then planning some more is what is necessary if we are to be competent-- if we are to strive for a gold standard in the rapid and reliable delivery of AEDs.

PAD proud

Long before the concept of rapidly and reliably delivering just about anything was considered, a wise man named Voltaire once said:

"Those who are occupied in the restoration of health to others by the joint exertion of skill and humanity are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create."

Know this, then. Our world is enriched because you have devoted yourself to help others and engaged in the noble task of deliberating ways to rapidly and reliably deliver your AED. Because of you--no doubt--so many more will survive!

Richard M. Obertots, MBA has more than 20 years experience with emergency medical systems and technology development and deployment. Since completing consulting with the Medical Review Panel of the TCIMS (Trauma Care Information Management System) he has focused on designing, implementing, managing and validating customized AED/PAD Programs for the meetings, conventions and hospitality, market. Rich is an active member, author and educator with the Professional Convention Management Association (PCMA - www.pcma.org). He is an advisor to NCED.

1 The author reminds the reader that this article takes into account that many PAD (AED) programs are initiated in environments in which one device is purchased, a limited number of staff are trained to use it and the distance and complexity to attain rapid and reliable AED delivery presents significant challenges.
2 The author utilizes a proprietary platform of probability discriminators. For the sake of brevity, a small number are provided for this use.
3 Most traditional emergency / safety services (EMS, Fire, Police, Rescue) have pre-arranged contingency agreements "Mutual Aid" that enable them to use each other's resources under circumstances when one or the other are overwhelmed. A word to the wise: prepare for situations in which "The Cavalry" may not be coming--or it may be significantly delayed.
- i Large group of people departing and entering during a shift change - people exiting a large gathering in a conference center, etc.
(c) 2000-2001 Richard M. Obertots, MBA