October 8, 1998

To:Emergency and Protective Services Committee

From:Acting General Manager Toronto Ambulance

Subject:Public Access Defibrillation (PAD)

Purpose:

To inform council of the benefits of public access defibrillation and improved cardiac care and response within the City of Toronto, and the requirements for the implementation of automatic defibrillation in City Hall and Nathan Philips Square.

Financial Implications:

The initial cost of acquiring three automatic defibrillators for the City Hall project is approximately $15,000.00. Funds for the acquisition of the defibrillators for this initial City of Toronto program will be reallocated from the Division's 1998 operating budget, and any impacts from the reallocation will be monitored in case of an unfavourable variance at year's end.

In addition, the cost of training, periodic recertification and medical oversight will be provided from existing funds of Toronto Ambulance. Should Council elect to expand the placement of defibrillators in other City of Toronto owned buildings (e.g. Community Council buildings), additional program costs would be required and would be detailed in a future report. The City of Toronto would not be responsible for any costs for public access defibrillation programs initiated by private organizations in their facilities.

Recommendations:

"It is recommended that:

(1)the City of Toronto Council endorse the concept of Toronto becoming a "Cardiac Safe City", actively encouraging public involvement in the provision of Cardiopulmonary Resuscitation (CPR) and wherever possible the use of Public Access Defibrillators (PAD); and

(2)Toronto Ambulance, in partnership with Sunnybrook and Women's College Health Sciences Centre, assume the lead role in promoting and coordinating the Cardiac Safe City program, inclusive of promoting greater public participation in learning CPR and the introduction of Public Access Defibrillation; and

(3)the appropriate City officials be authorized and directed to take the necessary action to give effect thereto."

Council Reference/Background/History:

At its meeting on October 2, 1998, Toronto Council approved Clause 1 of Report No.9 of the Emergency and Protective Services Committee, titled "Public Access Defibrillation Program". The report recommended:

the reaffirmation of Council's support of a Public Access Defibrillation Program within the City of Toronto

that the renovations to the Toronto City Hall incorporate the installation of automatic defibrillators in appropriate locations in City Hall and Nathan Philips Square

that the appropriate staff be trained in the use of automatic defibrillators, and

that the program be implemented by January 1, 1999.

In addition, the Emergency and Protective Services Committee requested a report regarding the feasibility of a Public Access Defibrillation pilot project in public buildings, statistics on the number of people who would benefit from PAD, and appropriate medical control.

Comments and/or Discussion and/or Justification:

The placement of automatic defibrillators to provide public access defibrillation holds the promise of shortening the time interval between initial patient collapse and the delivery of the first electrical shock for persons suffering from cardiac arrest, thereby improving the chance of survival. When a cardiac arrest occurs time is critical. The chain of survival depends on the following components:

early access including the immediate recognition of the emergency and calling 911

early intervention including cardiopulmonary resuscitation

early defibrillation either through Public Access Defibrillation or by a trained and authorized Public Safety Provider (Ambulance, Fire or Police), and

advanced cardiac intervention by Advanced Care Paramedics.

Medical Rationale:

"¼ an initial tachyarrythmia causes 80 to 90% of non-traumatic adult cardiac arrests. The goal of early defibrillation is to get a defibrillator to these patients before they deteriorate into a nonviable rhythm, which takes only a few minutes." "¼ defibrillation is the single most important intervention in adult emergency cardiac care". JAMA, 1992;268: p.2215.

The concept of early, rapid defibrillation, clearly endorsed by leading agencies such as the Heart and Stroke Foundation of Canada, Advanced Coronary Treatment (ACT) Foundation of Canada, EMS and Fire Associations and Emergency Physicians, is fairly new in Ontario pre-hospital care. Public Access Defibrillation programs have been established and have proven effective in many communities throughout North America and in Western Canada.

Application Within the City of Toronto:

The City of Toronto has a commitment to a highly respected emergency medical services system via universal 911 access, Toronto Ambulance and a tiered response program involving the Toronto Fire and Police Services. This provides a formidable link in the chain of survival, which benefits the community.

Currently ambulances and fire vehicles are equipped with defibrillators and this, combined with the availability of Advanced Care Paramedics, has resulted in improvements in cardiac arrest survival. To further enhance the chain of survival, implementation of public access defibrillation will shorten the time to delivery of first electrical shock. This is particularly important in a highly developed urban environment such as the City of Toronto where first response and Advanced Care Paramedics experience delays in access to patients due to high rise buildings and large public venues.

An assessment of several hundred cardiac arrest cases contained within the Sunnybrook Base Hospital and Toronto Ambulance database indicates that citizen intervention in providing CPR occurs in less than 13% of witnessed cardiac arrest cases. This compares unfavourably to other North American cities where citizen involvement is as high as 80%.

Citizen Participation and Promotion:

As a "Cardiac Safe City" the City of Toronto must encourage its citizens to become more actively involved in promoting healthy heart activities. One of the ways of doing this is to take CPR training. It has been proven that early recognition and intervention through bystander CPR combined with early defibrillation improves survivability and outcome in cardiac arrest situations. Chances of survival decreases by 7-10% for every minute a person waits for treatment. Toronto Ambulance, in conjunction with Sunnybrook and Women's College Health Sciences Centre, will take a lead roll in promoting greater public awareness and participation in learning CPR. This program would be undertaken in cooperation with the many agencies currently involved in providing CPR training.

These agencies include the Heart and Stroke Foundation, the Advanced Coronary Treatment (ACT) Foundation, St. John Ambulance and the Canadian Red Cross. Increased citizen involvement will provide a solid foundation for future enhancements in community cardiac care such as Public Access Defibrillation.

Public Access Defibrillation Locations:

A recent publication titled "Public Locations of Cardiac Arrest" noted that the 10 locations where there was a higher incidence of cardiac arrest were as follows:

Airports

Jails

Large shopping malls

Public sports venue

Large industrial sites

Golf courses

Shelters

Ferries/terminals

Health club/gym

Community and senior centres

(Source: Becker, Linda, MA (et al.), Public Locations of Cardiac Arrest Implications for Public Access Defibrillation, JAMA 1998;97:2106-2109)

Start Up Sites:

It is recommended that City Hall and Nathan Philips Square proceed as the first site for placement of automatic defibrillators. Implementation of a PAD program at City Hall will set an example for a Cardiac Safe City. This program is intended to encourage other organizations to consider the placement of defibrillators within their facilities and to provide a model for implementation. City Hall will initially be considered a pilot program. Other City of Toronto buildings and locations would be considered following an in-depth analysis of Sunnybrook Base Hospital and Toronto Ambulance's cardiac arrest database, to determine locations where sudden cardiac arrest is most likely to occur. In addition, consultation with the Medical Officer of Health and cardiac care agencies will provide valuable information for determining potential locations and high-risk target groups that would benefit from public access defibrillation programs within the City.

Program Coordination:

Advancements in equipment used for defibrillation have facilitated the safe and effective implementation of PAD programs. As a result, it is anticipated there will be rapid expansion in private sector locations where there is high public traffic or areas of potential cardiac risk. It is recommended that Toronto Ambulance and Sunnybrook and Women's College Health Sciences Centre coordinate the introduction of these programs and create a system to facilitate safe and effective cardiac care in the prehospital environment. This can be achieved in cooperation with the various suppliers and manufacturers of defibrillators and purchaser. Notification of Toronto Ambulance of the location of public access defibrillation programs within the community will establish strong communication within the links in the chain of survival. Medical control is a critical component in the program. Research, outcome monitoring and effective medical control are imperative to establish programs that most effectively serve the communities' needs.

Initial Program Costs:

The initial cost to acquire three automatic defibrillators for the City Hall project is approximately $15,000.00 which, for start up purposes, will be absorbed by Toronto Ambulance in recognition of the potentially significant benefits for cardiac patients, and for the longer term promotion of the program. A preliminary assessment indicates that the placement of a defibrillator in each of the towers and one defibrillator located centrally in the entrance way would be most effective. The cost of training, periodic recertification and medical oversight of this initial City of Toronto program would be provided from existing funds of Toronto Ambulance. Should Council elect to expand the placement of defibrillators in other City of Toronto owned buildings additional program costs would be detailed in a future report. The City of Toronto would not be responsible for any costs for public access defibrillation programs initiated by private organizations in their facilities.

Conclusions:

A pilot PAD project for City Hall and Nathan Philips Square can be implemented at a relatively low cost. The benefits of a Cardiac Safe City with high rates of citizen CPR and Public Access Defibrillation programs have proven to be valuable to the community. It is anticipated that these initiatives, commencing with the pilot project, will improve the survival rate for patients suffering sudden cardiac arrest outside of the hospital. Toronto Ambulance and Sunnybrook and Women's College Health Sciences Centre endorse the concept of a Cardiac Safe City, increasing public awareness of the need for citizen CPR, and the implementation of Public Access Defibrillation.

Contact Name:

Ronald L. Kelusky

Phone: 397-9240 Fax: 392-2115