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Public access AED programs

Question Type:
Intervention
Full Question:
Among adults and children who are in cardiac arrest outside of a hospital (P), does implementation of a public access AED program (I), compared with traditional EMS response (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, time to first shock, bystander CPR rates, bystander use of AED, time to commence CPR (O)?
Consensus on Science:
For the critical outcome of survival to 1 year with favorable neurologic outcome, we identified very-low-quality evidence (downgraded for risk of bias) from 1 observational trial(Cappato 2006, 553) enrolling 1394 patients showing improved outcomes with public-access defibrillation (unadjusted OR, 3.53; 95% CI, 1.41–8.79). For the critical outcome of survival 30 days with favorable neurologic outcome, we identified very-low-quality evidence (downgraded for inconsistency and indirectness) from 3 observational studies(Kitamura 2010, 994; Kitamura 2012, 2834; Mitani 2013, 1259) enrolling 182 119 patients demonstrating improved survival (range, 31.6%–55%) with public-access defibrillation compared with no program (range, 3%–37%). For the critical outcome of survival to discharge with favorable neurologic outcome, we identified very-low-quality evidence (downgraded for risk of bias, inconsistency, and imprecision) from 1 randomized trial(Hallstrom 2004, 637) and 3 observational studies.(Capucci 2002, 1065; Cappato 2006, 553; Berdowski 2011, 2225) The randomized trial enrolled 235 patients and found no difference in favorable neurologic outcomes (CPC, 1–2; RR, 1.73; 95% CI, 0.95–3.19). The observational studies included 4581 patients demonstrating improved survival (range, 4.1%–50%) with public-access defibrillation compared with no program (1.4%–14.8%), and 1 observational pilot study (20 patients)(Kuisma 2003, 149) showing reduced survival (0% versus 30.7) with public-access defibrillation compared with no program. For survival to 30 days, we identified very-low-quality evidence (downgraded for indirectness) from 3 observational studies(Kitamura 2010, 994; Iwami 2012, 2844; Mitani 2013, 1259) enrolling 14 135 patients demonstrating improved survival (range, 37.2%–65.5%) with public-access defibrillation compared with no program (23.3%–48.5%). If combined in a formal meta-analysis, a summary effect measure of OR 1.63 (95% CI, 1.41–1.88) would be generated. However, we recognize the limitations of significant heterogeneity in the study populations and the fact that some patient data were reported in more than 1 publication. For survival to discharge, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 randomized trial(Hallstrom 2004, 637) and 9 observational studies.(Capucci 2002, 1065; Culley 2004, 1859; Cappato 2006, 553; Fleischhackl 2008, 195; Rea 2010, 163; Weisfeldt 2010, 1713; Berdowski 2011, 2225; Weisfeldt 2011, 313; Swor 2013, 426) The randomized trial enrolled 235 participants and observed improved survival (adjusted RR, 2.0; 95% CI, 1.07–3.77). The observational studies enrolled 46 070 patients demonstrating improved survival (range, 4.4%–51%) with public -access defibrillation compared with no program (1.4%–25.0%) and 1 observation pilot study (20 patients)(Kuisma 2003, 149) showing reduced survival (0% versus 30.7) when public-access defibrillation programs were present.
Treatment Recommendation:
We recommend the implementation of public-access defibrillation programs for patients with OHCAs (strong recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we considered the societal impact of delayed defibrillation and balanced this against the costs of setting up a comprehensive public-access defibrillation program. We place a higher value on a single randomized trial supported by multiple large-scale, international observational studies. Together, these indicate that the magnitude of change on outcome may vary based on the setting or community within which programs are introduced. Public sites with large population densities may benefit the most from public-access defibrillation programs.
CoSTR Attachments:
BLS 347 1.0 Final Bias Assessment 20150114.pdf    
BLS 347 2.2 Evidence Profile Table 20150120.pdf    
BLS 347 3.0 Forrest Plots RevMan 20150114.pdf    

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