(OLA #: 032-04)

LEGISLATIVE ANALYST REPORT

To: Members of the Board of Supervisors

From: Andrew Murray, Office of the Legislative Analyst

Date: December 1, 2004

RE: Local Government Programs for Siting Automatic External Defibrillators (AEDs) in Public Spaces (File No. 041403)

Summary of Request

Supervisor Daly sponsored a motion requesting that the Office of the Legislative Analyst (OLA) examine the City's current policy on siting defibrillators in public buildings and analyze what other cities have done on this topic.

Executive Summary

Improvements in the ease of use and the falling cost of automatic external defibrillators (AEDs) have made their placement in emergency response vehicles widespread throughout San Francisco and other communities. In addition, because emergency responders often cannot reach cardiac arrest victims in sufficient time to provide aid, AEDs are being purchased by businesses and other organizations and placed in publicly accessible locations so that non-medical personnel can use them to attend to people who experience cardiac arrest at these locations. Programs to site AEDs in public places are called public access defibrillation (PAD) programs and are becoming increasingly widespread. As most PAD programs are relatively new, little long-term research on their cost-effectiveness has been conducted.

A number of communities in California and beyond have piloted programs to place AEDs in public buildings and are incrementally expanding their programs, but few have already implemented programs that provide broad coverage. The City of Los Angeles and San Diego County are exceptions, having placed over 500 AEDs each in public buildings. Some City and County of San Francisco department heads and facility managers have taken individual initiative to purchase and install AEDs in their buildings, but the City as of yet has no formal policy directing agencies to site AEDs in City-owned buildings. The fire department drafted a proposed policy, in response to a request from then Supervisor Newsom in 2000, which has not been implemented. The City is therefore in a position to consider adopting a program siting AEDs in public buildings and expanding its other AED programs.

Background, Current Law

Heart disease is currently the leading cause of mortality in the United States, and results in more than 1,500 deaths in San Francisco each year (average 1998-2000)¹. Most of these deaths occur from a syndrome called sudden cardiac arrest, which strikes twice per day in San Francisco², and is usually caused by a disturbance in the heart rhythm called ventricular fibrillation. The only procedure to successfully treat ventricular fibrillation is applying an electric shock to the chest, called defibrillation.³ For every minute that a person remains in ventricular fibrillation and defibrillation is not provided, the chances of resuscitation drop by almost 10 percent, until after 10 minutes, the chance of resuscitating a victim of cardiac arrest is near zero.⁴

In the mid-1980s, a new generation of defibrillators, called automated external defibrillators (AED), was introduced that was capable of interpreting a person's heart rhythm and automatically delivering a defibrillation shock when appropriate. People with basic medical training could safely use these. By the early-1990's it had become common for fire engines and ambulances (including basic life support ambulances not staffed by paramedics) to be equipped with AEDs, and more recently police patrol cars are being equipped. As a result, the survival rate of out-of-hospital cardiac arrest victims improved dramatically. However, fire engines, ambulances, and patrol cars often cannot reach cardiac arrest victims within ten minutes.

The ease of use of AEDs, the need for fast response, and the steadily decreasing price (now approximately $3,000, installed, with annual upkeep costs of $100)⁵, led to the concepts of early access defibrillation and public access defibrillation (PAD). Early access (or emergency employee) defibrillation and PAD attempt to reduce the time before defibrillation can be administered to a cardiac arrest victim by locating AEDs throughout communities and increasing the number of users by providing training to non-medical personnel. In early access defibrillation programs, specific non-medical personnel are trained in operating AEDs and are the only people authorized by the owner of the AED to use the device in responding to cardiac arrest emergencies. PAD is a situation in which the owner of an AED places it in a publicly accessible location and authorizes its use by any lay community member (not just designated individuals) who is in a position to respond to a cardiac arrest emergency. Appendix A contains a list of publicly accessible locations identified by researchers as being of high cardiac arrest incidence. The American Heart Association estimates that widespread availability and use of AEDs could save 50,000 lives in the U.S. each year.⁶

An increasing number of government agencies have acted to expand the prevalence and use of AEDs by adopting the following practices and programs:

- Public education to promote awareness;

- Training to volunteers in operating AEDs;

- Information to buyers on AED devices and vendors;

- Requiring registration of AEDs with the local emergency medical services department;

- Requiring registration of physicians who prescribe AEDs with the local emergency medical services department;

- PAD program management guidelines;

- Siting AEDs in publicly-owned buildings; and

- Requiring or requesting AEDs in publicly leased buildings.

Most government programs addressing PAD are relatively new, and little long-term research has been conducted on the value and cost effectiveness of the programs. Recent studies have shown that the use of AEDs by trained volunteers nearly doubled the survival rate of cardiac arrest victims in community settings when measured against the survival of people who only received CPR.⁷ However, some researchers have also concluded that PAD is excessively expensive in terms of the number of quality-adjusted life years gained.⁸ More thorough research findings should soon be forthcoming as more local government programs are implemented, many of which have a reporting requirement regarding incidence of public AED use.

Federal and state law relating to PAD

The federal government has passed a number of laws that address AEDs. Among other things, these laws govern liability, regulate their manufacture, require federal buildings to site AEDs, require commercial airlines to site AEDs, and provide limited funding to urban and rural communities to purchase AEDs and train non-medical personnel in their use.⁹ A more thorough discussion of federal policies regarding PAD programs and liability issues can be found in Appendix B.

Between 1997 and 2001, all fifty states adopted regulations addressing PAD programs. According to the American Heart Association¹⁰, California state law¹¹ provides Good Samaritan protection from civil damages liability to any person who renders emergency care in good faith using an AED, whether or not they have received certified CPR and AED training. California law also protects from liability any person or entity that owns an AED provided that the person or entity has complied with provisions of the Health and Safety Code^12,13. An overview of legal issues relating to PAD programs can be found in Appendix C, an American Heart Association factsheet.

Current San Francisco AED Programs

The City and County of San Francisco currently has a number of programs involving AEDs. All of the City's fire engines and ambulances are currently equipped with AEDs, as the result of an effort started in 1987. The San Francisco Police Department is currently engaging in a pilot project to equip patrol cars with AEDs, as police officers are often the first responders on the scene of medical emergencies. MUNI will kick off an effort in late 2004 to install AEDs at each of their major maintenance facilities as well as site an AED at the Powell Street Station, an initiative undertaken jointly with the fire department.

The San Francisco Department of Public Health, Emergency Medical Services (EMS) section oversees a program to promote and regulate the placement of public AEDs. The department regulates AEDs by requiring that any doctor that wishes to prescribe an AED must be registered with EMS and specifies user training and equipment maintenance requirements. The department also promotes the placement of AEDs by providing a list of physicians who are registered to prescribe them, a list of equipment vendors, and a list of individuals and organizations qualified to train volunteer AED users. The registry of that program indicates that there are currently 108 organizations/facilities throughout the city that have AEDs, of which 15 are public organizations/facilities (see Appendix D for a complete list). The placement of AEDs in City-owned buildings is a result of individual initiative on the part of department heads and facility managers at the City, not the result of a particular central policy promoting placement. The fire department drafted a proposed policy, in response to a request from Supervisor Newsom in 2000, but that has not been implemented.

Programs In Other Jurisdictions

In an effort to determine the standard and best practices of local government PAD programs, the OLA communicated with local and regional experts and collected information on leading programs. These programs include the cities of Anaheim, Los Angeles, Oakland, Seattle, and Sunnyvale, the counties of Contra Costa and San Diego, the California Department of General Services, the federal General Services Administration, and San Jose International Airport. The OLA's findings are summarized below.

The City and County of San Francisco's program to promote placement of AEDs by public and private organizations by providing guidance and support services, but no funding for the purchase of AEDs, is an approach emulated by other jurisdictions. San Francisco's program was the first of its kind in the state, and now 5 other jurisdictions, including Contra Costa and San Diego counties, have similar programs. Some of these programs are funded on a fee for service basis.

A number of communities have pilot or small-scale programs to place AEDs in public buildings, including Oakland and San Jose. Apart from formal pilot programs, many jurisdictions have sited AEDs on an ad hoc basis at a limited number of public buildings as the result of individual initiative on the part of department heads and facility managers absent directives from local policy makers.

A small number of jurisdictions have large-scale programs. These include the federal government, the State of California, and the cities of Los Angeles, San Diego, and Seattle. The federal government is requiring that all federal facilities site AEDs, and the State of California will soon likely issue a management memorandum directing all department heads to site AEDs in their buildings. In addition, the State is considering requiring that state leased buildings also be equipped with AEDs. Los Angeles has sited over 600 AEDs at public facilities such as the airport, city office buildings, community centers, convention center, golf courses, harbor, parks, swimming pools, and zoo. Seattle has sited more than 700 devices at similar locations. The State of New York requires that all public schools with 1,000 or more students have AEDs, which is the only requirement of this kind in the country. See Appendix E for additional information on the number of public AEDs, locations, and funding sources employed by other jurisdictions. Government policies to establish PAD programs can take many forms, including directives by executives like fire chiefs, city managers, department heads, and mayors and acts of city councils and other elected bodies (see Appendix F, the City of Los Angeles motion).

The sources of funding of public PAD programs are diverse. Some pilot projects have been supported by seed grants from the federal government or donations of equipment from vendors. Others have been funded by donations, such as those to fire department related charities which in turn are used to purchase AEDs. Some jurisdictions have solicited donations from charitable organizations such as the Rotary Club to place AEDs in locations like schools and senior centers. In Contra Costa County, funds from a local measure for paramedic enhancement (Measure H) were used to purchase AEDs. In some cases firefighters or paramedics provide training on time they have volunteered. Few jurisdictions have large pools of resources that can be devoted to PAD programs, which partially explains why there are few programs that thoroughly place AEDs in public buildings. Seattle and the State of California both require that departments budget for them. The City of Los Angeles' initial 600+ AEDs were acquired using general fund, but a new motion that is being considered and would require all of the City of Los Angeles' public buildings to have AEDs directs departments to find sources of funding other than the general fund.

Not a single case could be uncovered of a jurisdiction requiring that private organizations provide AEDs in places where large numbers of people pass or assemble, with the exception of the FAA requiring such of commercial airlines. Although no private companies are required to site devices, many companies that operate large facilities have implemented programs of their own accord. As such, some communities have determined that they do not need many AEDs in public buildings, because most of their large places of assembly are private, and already served by a public AED. One example is the City of Vallejo, whose largest places of assembly include Marine World and the ferry building, both of which are operated by companies that have sited AEDs.

Conclusion

The low cost and obvious benefits of AEDs have encouraged many local government agencies and other organizations to site them in their buildings on a pilot or more widespread basis, despite uncertainty regarding their cost effectiveness and liability issues. San Francisco already has a number of programs in place involving PAD and AEDs. The City is therefore in a position to consider the following additional actions, beyond maintaining its current programs:

- Broader placement of AEDs in City buildings;

- Additional effort to encourage the siting of AEDs by private organizations, particularly those with large facilities or with large places of assembly;

- Requiring or encouraging the placement of AEDs in City-leased buildings;

- Wider placement of AEDs through the police department; and

- Placement of AEDs in MUNI and BART transit vehicles.

Appendix A - Locations Recognized by Researchers as Being of High Cardiac Arrest Incidence¹⁴

Airports
Businesses
County jails
Dialysis centers
Gaming establishments
Golf courses
Homeless shelters
Hospitals
Industrial sites
Nursing homes
Physician offices
Shopping malls
Sports complexes
Streets and highways
Trains and ferries

Appendix B - Federal policies regarding AEDs

The federal government has enacted a number of policies that address AEDs. These policies regulate their manufacture, require federal buildings to site AEDs, require commercial airlines to site AEDs, and provide funding to urban and rural communities of limited resources to purchase AEDs and train non-medical personnel in their use.

According to the National Center for Early Defibrillation, the Federal Cardiac Arrest Survival Act (CASA) (HR 2498, 2000) directed the Department of Health and Human Services to develop guidelines for PAD programs in federal facilities. The "Guidelines for Public Access Defibrillation Programs in Federal Facilities" provide guidance on where to place AEDs and suggest procedures for training, maintenance and testing, medical oversight, and coordination with local emergency responders. CASA also provides Good Samaritan liability protection to AED owners, users, trainers, and prescribing physicians.

The Rural Access to Emergency Devices Act (public law 106-505) authorized federal funds to help rural communities purchase AEDs and train lay rescuers. The Community Access to Emergency Defibrillation Act (public law 107-188, 2001) is an urban counterpart that provides limited funding ($50M in 2001) for local government agencies to establish PAD programs.

The Airline Passenger Safety Act (1998) required that the Federal Aviation Administration (FAA) review the required contents of medical kits carried on commercial airlines. As a result, the FAA established a rule requiring that commercial airline carriers provide AEDs by 2004 and train flight crews.

Because AEDs are medical devices, the Food and Drug Administration oversees their manufacture, and also determines, along with state level regulators, who can use AEDs and how they can be used.¹⁵

Appendix C - American Heart Association PAD Program Legal Issues Factsheet (PDF)

Appendix D - AEDs Registered with the San Francisco Department of Public Health, Emergency Medical Services Section (PDF)

Appendix E - California Jurisdictions that have Placed AEDs in Public Locations¹⁶

Appendix F - City of Los Angeles Motion Preparing for the Rollout of the PAD Program

File Number
99-0186

Last Changed Date
5/21/2002

Title
DEFIBRILLATORS AND TRAINING

Initiated By
Svorinich, Jr. Mover 1999 / Chick

Subject
Motion - According to the American Heart Association, approximately 350,000 people a year are stricken with sudden cardiac arrest. The arrest is caused when the heart spontaneously starts to quiver as the result of the normal electrical pulse going out of control. When the arrest occurs the only effective way of treating the heart is with an electric shock. What is important to note is that for every minute that the heart quivers rather than beats regularly, the chance to survive diminishes ten percent.
Statistics show that only 5% of sudden cardiac arrest victims survive and in large cities where it can take several minutes for a paramedic ambulance to arrive at the scene every minute can count. A recent article in U.S. News and World Report stated that fewer than 2 out of 100 persons survive cardiac arrest in New York City.
However, new and relatively inexpensive technology is now available to increase the chances of persons surviving a sudden cardiac arrest if deployed strategically. Now available on the market are small, automated external defibrillators which can be utilized with a minimum amount of training to the operator. The instrument is available through various distributors for approximately $3,000 and is relatively easy to use. Recent statistics have shown a survival rate as height as 7 out of 10 when the defibrillator was deployed in an emergency situation.
THEREFORE MOVE that the Fire Department, with the assistance of the City Administrative Officer (CAO) and City Legislative Analyst (CLA), report back to the Council's Public Safety Committee within 45 days on the feasibility of deploying automated defibrillators strategically at city facilities where the public gathers frequently and a plan to train city personnel is in use.
FURTHER MOVE that the City Attorney be requested to report on any potential city liability that could be incurred by trained city staff deploying such a device in an attempt to save a life, whether successful or not.
FURTHER MOVE that the City Administrative Officer (CAO) and City Legislative Analyst (CLA) make contingent preparations to include funding for these devices for citywide distribution in the 1999-2000 city budget - all other issues having been addressed - by the time budget deliberations begin in May 1999.

Date Received
2/2/1999

File History
2-2-99 - This days Council session
2-2-99 - File to Calendar Clerk for placement on next available Council agenda
2-9-99 - CONTINUED TO February 10, 1999
2-10-99 - Motion ADOPTED
2-16-99 - File in files
2-22-99 - File to Public Safety Committee Clerk
7-19-99 - City Administrative Officer (CAO) 0220-03458-0000 report received re: Bicycle Medic Program - to Public Safety Committee Clerk
9-14-99 - City Administrative Officer (CAO) 1000-00001 report received re: Request for the Emergency Operations Board (EOB) to coordinate a Citywide Automated External Defibrillator Implementation Plan - to Public Safety Committee Clerk.
9-15-99 - Los Angeles Fire Department (LAFD) report received re: Bicycle Medic Program - to Public Safety Committee Clerk
11-16-99 - No Quorum
11-17-99 - Public Safety Committee report ADOPTED to:
a. Coordinate the establishment of, and convene an AED Implementation Task Force consisting of representatives of the Fire, Personnel, Police, Zoo, and Library Departments; the Departments of Aging, Airports, General Services, and Recreation and Parks; the Los Angeles Convention Center; other City departments as necessary; the American Red Cross; and, the American Heart Association to evaluate the feasibility of specific Automated External Defibrillator (AED) programs, such as deploying bicycle Automated External Defibrillators (AEDs) at major public events.
b. Report back to the Public Safety Committee in 45-60 days with a detailed Automated External Defibrillator (AED) deployment cost analysis and with recommendations for implementation, funding, and pilot programs.
11-24-99 - File to Public Safety Committee Clerk OK
11-30-99 - File in files
2-24-00 - For ref - City Administrative Officer (CAO) 0220-03458-0001 - Request Council approve formation of an Automated External Defibrillator (AED) Implementation Task Force.
2-25-00 - Ref to Public Safety, Budget and Finance and Personnel Committees
2-25-00 - File to Public Safety Committee Clerk
3-14-00 - File to Budget and Finance Committee Clerk per Public Safety Committee Clerk request
5-15-00 - RECEIVED and FILED
5-23-00 - File to Public Safety Committee Clerk OK
5-25-00 - File in files
10-3-00 - File to M.Gonzales-Kimbrough - City Attorney -x57112
10-23-00 - File in files

¹ San Francisco Department of Public Health, 2002 Overview of Health Status: Who We Are, How We Live, Our Health

² San Francisco Fire Department, per conversation 11/16/04 with Medical Director Marshal Isaacs.

³   www.emedicinehealth.com, National Center for Early Defibrillation

⁴   www.emedicinehealth.com, National Center for Early Defibrillation

⁵ Per conversation 11/12/2004 with Robert Cavaglieri of the City of Beverly Hills Fire Department, corroborated by other sources, including SFFD Medical Director Marshal Isaacs. Includes AED, medical cabinet, signage, and supplies, not training.

⁶ American Heart Association

⁷ Medical College of Wisconsin study primarily funded by the National Institutes of Health Heart, Lung and Blood Institute and the American Heart Association.

⁸ http://www.heartcenteronline.com/myheartdr/home/research-detail.cfm?reut...

⁹ National Center for Early Defibrillation

¹⁰ American Heart Association, AED Legislation Update (Good Samaritan)

¹¹ California Health and Safety Code Sections 1797.5, 1797.107, 1797.190

and 1797.196, California Code of Regulations Title 22, Division 9, Chapter 1.8 Sections

100031 through 100043, SB 911 (1999), and AB 2041 (2002)

¹² Health and Safety Code Section 1979.196 (b) and Title 22, California Code of Regulations, Division 9, Chapter 1.8

¹³ American Heart Association, AED Legislation Update (Good Samaritan)

¹⁴ National Center for Early Defibrillation

¹⁵ National Center for Early Defibrillation

¹⁶ Information gathered through communication with agency staff and online resources.