Automated External Defibrillators in Fitness Facilities

What to consider when implementing an AED program in your health club.

Numerous states now require fitness facilities to have at least one automated external defibrillator (AED) on-site, along with trained staff. As of press time, there are 10 of these states—Arkansas, Calif­ornia, Illinois, Indiana, Louisiana, Massa­chusetts, Michigan, New Jersey, New York (for clubs with more than 500 members) and Rhode Island—plus Washington, DC. Legislation is pending in other states.

While some state laws mandate AEDs in health clubs, fitness facility owners and managers in nonmandated states may choose to implement an AED program for diverse reasons: the investment not only helps save lives but also makes good business sense, since many older adults are joining fitness facilities.

Club managers and directors who have implemented AED programs in their facilities agree that phasing in the program requires a certain amount of launch time. Let’s say you’ve decided to equip your club. Where do you begin? This article describes how AEDs can help save members’ lives. It also provides useful hints from experts and experienced managers in the field regarding what has and hasn’t worked in getting an effective AED program off the ground.

Saving Members’ Lives

“The likelihood of surviving a sudden cardiac arrest (SCA) in facilities with an AED program is significantly higher than in the case of most SCAs that take place outside of a hospital setting—75% versus less than 5%,” says Kyle McInnis, ScD, professor and chair in the department of exercise and health sciences at the University of Massachusetts at Boston. Also, the risk of an SCA occurring is 15–20 times higher during exercise than at rest, according to McInnis. In addition, an SCA is more likely to happen to new rather than experienced exercisers, since the risk of a cardiovascular event is higher among those who are deconditioned than among those who are fit. Facilities that cater to new exercisers or older adults, in particular, should consider the benefits of implementing an AED program.

Colin Milner, chief executive officer of the International Council on Active Aging®, based in Vancouver, British Columbia, concurs. “As head of an association that supports professionals who develop wellness and fitness facilities and services for adults over 50, I believe that an AED should be part of a facility’s emergency preparedness plan,” he says.

YMCAs nationwide report more than 100 instances of members’ lives being saved because of AEDs, says Michael Spezzano, former national health and fitness director for the YMCA of the USA and current editor and project coordinator of the YMCA’s technical assistance paper on AEDs. Approximately 62% of all facilities have AEDs, according to 2005 data from the YMCA of the USA (Larkin 2007). AED programs have been successful in for-profit clubs, too. Town Sports International (TSI) reports that members’ lives have been saved since the inception of their program in 2005.

“Victims of cardiac arrest range in ages from mid-30s to 60s,” says Veronica Hyatt, senior director of corporate club support for TSI, based in New York City. “In a health club environment, it is really only a matter of time before you have the opportunity to use your defibrillator. [Because] response time is usually only a few minutes, the chances of survival increase dramatically. Since implementation, TSI has had a 90% save ratio. In 2007, TSI had a save ratio of more than 95%, which is well above the industry standard.”

Keys to Successful AED Programs

The following guidelines for establishing an AED program in a workplace setting are compiled from recommendations by the American Heart Association (AHA), the American Red Cross and the American College of Occupational and Environmental Medicine (ACOEM). Experts with in-depth field experience have provided comments to each of the guidelines to further illustrate these points.

Centralized Management

Experts agree that when you establish an AED program, you need to identify who will be responsible for program ownership. The ACOEM recommends a centralized management system that defines clear lines of responsibility for those who oversee and monitor the program.

The AHA recommends that a dedicated program coordinator manage day-to-day activities and foster communication with key decision-makers, particular program responders, employees and the public. Program decision-makers can include club owners, managers, board members and staff who are involved with risk management, legal issues, human resources and environmental health and safety for the facility.

TSI has found that having fewer managers often yields better results. “Over the years, we have noticed that if we rely on a smaller group of individuals to be responsible for the clubs’ defibrillators, it ensures efficiency and accuracy when processing replenishments, trade-ups and upgrades,” says Hyatt.

Medical Direction

A medical prescription is necessary to buy an AED, according to regulations set by the U.S. Food and Drug Administration. As a practical matter, this means that your facility needs to find a physician to serve as medical director for your AED program (AHA 2008). The program coordinator can consult with this medical director regarding medical issues, the AED purchase and approval of the initial AED training.

To locate a medical director in your area, the AHA recommends checking with your local or state emergency medical services (EMS) office or local and state medical societies, particularly those involving emergency medicine doctors. Some local Red Cross chapters team up with medical directors to purchase AEDs and can help community organizations with buying an AED and training staff.

Organizations that sell AEDs can also provide support in locating a medical director. Philips Medical Systems, based in Andover, Massachusetts, offers comprehensive AED HeartStart program management for facilities that want to purchase an AED and launch on-site programs. The package includes program management, medical direction, staff training and several financing options. For more information, go to www.medical.philips.com/main/products/resuscitation/products/heartstart_essentials/.

Federal, State and Local Compliance

AED programs are regulated under federal, state and local laws. Federal law includes the Cardiac Arrest Survival Act, which grants limited immunity for lay rescuers and acquirers of AEDs. State laws fall under the category of public access defibrillation (PAD) and govern what types of training are required (such as those provided by nationally recognized trainers of cardiopulmonary resuscitation [CPR] and AED skills). State laws also mandate that local EMS providers be notified when you implement your AED program. Some state laws require that CPR and AED skills be reviewed and practiced at least annually, while others encourage reviews every 6 months.

Understanding the prevailing laws in your state can be problematic. For example, states that require AEDs at fitness facilities also mandate that a trained staff person be on duty during all operational hours. “I found it difficult to find government assistance with understanding the laws,” says Donna Baia, founder and director of Fitness 4 Fun® in Pompton Plains, New Jersey. When implementing her club’s AED program, Baia used some of the online resources listed in the sidebar “Other Agency Recommendations” for information and clarification.

Complying with legal staffing regulations can be especially difficult during the start-up stages, when all staff might not yet be trained. Problems can arise when employees change schedules at the last minute and a CPR/AED-trained substitute is required to fill the slot. “The goal is to eventually have everyone [on staff] trained and kept current,” says Baia.

Mary O’Donoghue is the aquatics specialist at the YMCA of Greater New York in New York City. “It helps if you have staff members who are trainers for nationally acknowledged organizations,” she says. “For example, we stay up-to-date because many of our staff members are American Red Cross [CPR/AED] instructors. Every 5 years at the International Cardiac Conference, CPR protocols are updated. Some years, it’s minor; sometimes it’s major. After the conference, the CPR/AED trainers are the first to be updated. Any hardware updates usually occur within the next 6 months after that. Also, both the [AED] manufacturer and the city department of health notify us of any changes.”

If you still need help with program compliance, there are other outlets, such as AED manufacturers or outsourcing. “Vendors can help sort [all the regulations] out,” says McInnis. “It’s important to realize that it is not as complicated as it may appear.”

TSI uses outsourcing as a strategy. “Most fitness organizations have their AED programs managed by an outside company, and these companies are familiar with local laws,” says Hyatt. “Emergency Skills Inc. monitors all laws for TSI and assists us in managing what is required. The International Health, Racquet & Sportsclub Association also monitors changes in state laws, and Philips [the manufacturer of TSI’s AEDs] notifies us of changes that are required.”

Finally, it’s a good idea to consult with local legal counsel to determine whether your overall emergency plan, including the use of AEDs, meets the applicable standard of care for providing emergency aid in your locale.

Written AED Program Procedures

The AHA and other experts recommend that written procedures should guide AED program implementation. You should integrate the AED procedures into an overall emergency response plan that governs all your facility’s emergencies, both medical and nonmedical. A mechanism should be in place in your club to ensure that all employees receive notification of the emergency response plan. AED program procedures will be part of the emergency medical response plan.

The AHA recommends that you document the following plans:

  • The Internal Medical Emergency Response Plan. Lay out step by step how the emergency response is activated. Indicate where the AEDS are located and how they are accessed.
  • The Training Plan. Describe who will be trained; what training course will be used; where trainings will occur; when trainings will be renewed; and how skills will be reviewed.
  • The Maintenance Plan. Cite who is responsible for maintaining the units and stocking and reordering supplies; what maintenance procedures are required; when checks will occur; and how maintenance will be recorded.
  • The Transfer of Patient Care Plan. Define how patients are to be transported after an event and how this should be coordinated with local EMS.
  • The Postevent Procedures Plan. Set forth how responders will be debriefed; how equipment is to be checked after use; and how to evaluate the entire event to determine what, if any, new strategies should be incorporated to improve future responses.

Coordination With Local EMS

Most states require that fitness facilities coordinate their AED program with local EMS. The reason for this requirement is to ensure smooth communication with the EMS and an integrated response with EMS providers. Once your facility is equipped with an AED, it becomes part of a more comprehensive “chain of survival” that can improve the recovery odds for an SCA victim.

Here again, this is an area in which AED vendors or trainers may prove helpful. The Philips HeartStart package, mentioned previously, includes support in contacting local EMS. Local American Red Cross chapters may include this same service if AED units are purchased directly through their organization. Baia, as a one-club owner, has supplied the local EMS squad with the AED prescription for her facility and displays the AED sign in the front window of her studio.

Selecting the Right AED Product

When choosing an AED device for your facility, all experts agree that doing your homework first is essential. “Go online, Google [the keyword] ‘AEDs’ and it will give you a lot of companies,” advises O’Donoghue. “Read as much as you can. Learn about the different organizations. Today there are a lot of choices and many companies.”

McInnis says other fitness facilities are a good source for information. “If you don’t know where to turn, find a similar club that has been successful [in running its AED program], and share ideas or concerns.”

You can also contact the AHA or the American Red Cross for advice and support.

Required Ancillary Medical Equipment & Supplies

Keep in mind that you will need products to support an AED program in your facility, some of which may not be included with the AED device. “The AHA and the American Red Cross provide information in their first-aid manuals about what you need for your first-aid and medical-response kits,” says O’Donoghue.

Some clubs work with service providers who provide the required regular maintenance checks on AEDs and who stock all necessary supplies. Kits can also be purchased from vendors. “I purchased a full-blown first-aid box from Cintas, which also sells AEDS and can provide a doctor’s approval providing that you meet the requirements necessary,” says Baia.

The ACOEM lists the following examples of additional equipment supplies you may need:

  • blood-borne pathogens responder and cleanup kits
  • CPR barrier masks
  • AED responder kits to support electrode pad connections (e.g., a razor to shave chest hair and a towel to dry sweat from the chest or to dry the skin after removal of a nitroglycerine transdermal patch)
  • portable emergency oxygen equipment to increase oxygen during resuscitation and support inhalation following restoration of breathing
  • a CPR audio prompting device to guide action and timing sequences of CPR ventilations and compressions

Determining AED Type, Number and Placement

One key consideration of any program is exactly how many AEDs your facility will need, along with where those devices will be positioned. Experts say the answers will depend on many factors, such as facility size and configuration.

“The number of units issued [should be] based upon estimated response time,” says Hyatt. “The goal is to deliver a shock to a patient within 3–5 minutes of cardiac arrest. Therefore, ideally, defibrillators [should be] no farther than a 60- to 90-second brisk walk from anywhere in the facility.” This time—known as the “drop-to-shock” interval—is in keeping with AHA guidelines. O’Donoghue and Baia recommend that you add another unit if your facility has a swimming pool.

Typically, vendors will help you determine what type of AEDs will be required at your facility and how many units you will need. Depending on how large your facility is and how many units you may be purchasing, this service may come at no extra charge. Prices vary, depending on what type of unit you buy. The purchase of AED units can be bundled with training and with medical direction, if needed. Special financing and equipment loan options are also offered, as well as indemnification.

Each AED in your facility should be placed in a visible and easily accessible location inside an alarmed cabinet and furnished with an overhead sign. The YMCA of the USA and other agencies recommend that AED cabinets not be secured. An emergency responder should not need a key or code to get to the AED unit, as time is of the essence in an emergency.

Creating a Maintenance/Replacement Schedule

After you have chosen the AED appropriate for your facility, it’s important to follow the manufacturer’s guidelines for maintenance and replacement. Keep records of all tests, maintenance services and replaced items. In addition to periodic maintenance, have all equipment checked immediately after any incident requiring use. Batteries should be checked on a monthly basis to make sure they are always charged, are ready for use and have not expired.

Program Review and Modification

A few months after you launch your program, it’s important to step back and review it. During this review, program leaders can assess what is and isn’t working and make appropriate modifications. For example, after a few drills, it might be determined that the AED unit should be stored in a more accessible location. Adjustments can also be made to training schedules to ensure that enough staff members are fully trained and that new employees are easily integrated into the system, since staff turnover can be high in fitness facilities.

How do you know if your program is working? “Drills are the best way to determine how well your protocols work, and should be done at least quarterly,” says O’Donoghue. “Staff may be successful in a training, but actually doing a drill makes sure that everyone can do [what’s required in an emergency involving an AED]. Each facility needs to design a drill for its own location. There are lots of templates for it. The AHA, American Red Cross and local EMS can help you with it.”

Make It Happen

Now that you know some of what’s involved in implementing an AED program, be a proponent for making changes in your fitness facility.

“A health club without an AED program is like a pool without a lifeguard—it simply should not happen,” says McInnis. “Any perceived barrier that [club decision-makers] think is a reason not to implement an AED program can be addressed successfully.” McInnis says that clubs of any size, from single facilities to large national-chain clubs, can find excellent models to follow when establishing a successful emergency response program that includes AEDs. “Modern technology makes AEDs virtually idiot-proof and affordable. Good Samaritan laws protect emergency responders.”

There is also the greater good to consider. If our mission is to Inspire the World to Fitness®, shouldn’t we do so in an atmosphere that optimizes the health, well-being and safety of each participant? If a member dies in your club who could have been saved if an AED program had been in place, keep in mind that no amount of regret will restore that person to life. Isn’t it time to take action?

SIDEBAR: Professional AED Standards & Guidelines

The American Heart Association (AHA) and the American College of Sports Medicine (ACSM) have adopted a formal position regarding automated external defibrillators (AEDs) in health clubs and fitness facilities. Their 2002 Joint Position Statement is called “Automated External Defibrillators in Health/Fitness Facilities” and is a supplement to their 1998 Joint Position Statement titled “AHA/ACSM Recommendations for Cardiovascular Screening, Staffing and Emergency Policies at Health/Fitness Facilities.” (Note: The AHA guidelines were updated in 2005. However, according to Christa Dickey at ACSM, the 2002 guidelines are still the most up-to-date guidelines for AEDs, since the 2005 changes did not impact AED standards.)

The following briefly summarizes the AHA/ACSM guidelines for fitness facilities that have an AED program:

  • Written emergency policies and procedures should be reviewed and practiced regularly.
  • Facility staff members should be well-trained in AED use.
  • Effective placement and use of AEDs is encouraged, as permitted by law, to achieve the goal of mini­mizing time between recognition of cardiac arrest and successful defibrillation.
  • AED placement is strongly encouraged for clubs with a large number of members (more than 2,500); those that offer special programs to clinical populations; and those in which the time from recognition of cardiac arrest until the first shock is delivered by EMS is anticipated to be more than 5 minutes.
  • Health/fitness facilities should coordinate their public access defibrillation program with local EMS.
  • Emergency drills should be practiced at least once every 3 months, or more often when staff changes occur.
  • Public access defibrillation programs must comply with local or regional regulations and legislation.

Source: Balady, G.J., et al. 2002. Automated external defibrillators in health/fitness facilities: Supplement to the AHA/ACSM recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circulation, 105, 1147–50. Reprint no. 71–0222, available at www.acsm.org or www.americanheart.org.

SIDEBAR: Other Agency Recommendations

In addition to the formal standards governing use of AEDs in fitness facilities, other agencies have issued statements and standards that are helpful.

International Health, Racquet & Sportclub Asssociation. After significant research, IHRSA has concluded that, in states where AEDs are not statutorily required in health clubs, there is not a legal standard of care that governs all fitness centers. However, IHRSA does encourage health club operators to consider the advantages of installing AEDs in their facilities (IHRSA 2008).

International Sports Sciences Association. ISSA, a Southern California–based teaching institution and certification agency for fitness trainers, is now requiring all U.S. students who enroll in a certification course to submit copies of AED and basic adult CPR certification. A student’s ISSA certification is valid only after successful completion of an ISSA examination and submission of CPR/AED documentation (ISSA 2008). For details, go to www.issaonline.com.

Medical Fitness Association. The MFA’s standard requires that all medical fitness centers have at least one AED device easily accessible for use (MFA 2006). It also encourages any multiple-story buildings or large facilities (more than 30,000 square feet) to consider having additional AED units. AED placement should be determined by the response time required and the distance that must be covered to take the AED to the victim. (The AHA recommends a response time of 3 minutes or less). Additionally, all staff should have current CPR/AED training. For more details, go to www.medicalfitness.org.

YMCA of the USA. The YMCA of the USA’s medical advisory committee endorses the AHA’s position on the use of AEDs and strongly recommends that YMCAs have the devices available in their facilities and programs (YMCA of the USA 2006).

SIDEBAR: Working With a Medical Director

Medical directors in your area can help with a variety of issues before, during and after you launch an AED program in your club. Here are some areas in which medical directors can answer questions or provide assistance:

  • knowing what type of AED to purchase
  • deciding how many units to buy and where to place them in your facility
  • determining which protocols to create for AED use
  • providing a medical prescription to purchase an AED
  • serving as the liaison to local EMS
  • approving your club’s AED training program
  • acting as your program spokesperson and advocate
  • assisting with AED maintenance, review and program improvement plans
  • ensuring that your plan complies with local and state rules and regulations
  • supporting and guiding the development of internal and external communication plans
  • conducting a post-incident review each time the AED is used

Source: Larkin, M. 2007. Should your facility have an AED? The Journal on Active Aging (May-June), 56–60; and American Heart Association. 2004. AED Implementation Guide. Publication no. 70–2272.

SIDEBAR: Additional AED Resources

  • To help launch your facility’s AED program, the AHA has created a program implementation guide available online at www.americanheart.org/presenter.jhtml?identifier=3027304.
  • The American Red Cross can also provide information regarding program implementation at www.redcross.org/services/hss/courses/aed.html#buy.
  • The National Conference of State Legislatures provides summaries and updates in a document titled “State Laws on Heart Attacks, Cardiac Arrest & Defibrillators” at www.ncsl.org/programs/health/aed.htm.

SIDEBAR: AED Vendors

Here is a partial list of manufacturers and distributors of AEDs:

  • AED Superstore®, www.aedsuperstore.com
  • Cardiac Science Corporation, www.cardiacscience.com
  • Cintas Corporation, www.cintas.com
  • Medtronic, www.medtronic.com
  • Philips Medical Systems, www.philips.com
  • Welch Allyn Medical Products, www.welchallyn.com
  • ZOLL Medical Corporation, www.zoll.com

Shirley Archer, JD, MA, is an IDEA contributing editor and spokes­person, a certified fitness professional, a mind-body movement and wellness expert, a health educator and an award-winning author of Pilates Fusion: Well-Being for Body, Mind and Spirit. Contact her at www.shirleyarcher.com.

References

American Heart Association (AHA). 2008. AED programs q & a. http://americanheart.org/presenter.jhtml?identifier=3011859; retrieved Jan. 15, 2008.

International Health, Racquet and Sportsclub Association (IHRSA). 2008. Automated external defibrillators (AEDs). http://cms.ihrsa.org/index.cfm?fuseaction=Page.viewPage&pageId=18800&nodeID=15; retrieved Jan. 15, 2008.

International Sports Sciences Association (ISSA). 2008. Frequently asked questions. www.issaonline.com/faq/index.cfm; retrieved Mar. 10, 2008.

Larkin, M. 2007. Should your facility have an AED? The Journal on Active Aging (May-June), 56–60.

Medical Fitness Association (MFA). 2006. The Medical Fitness Model: Standards and Guidelines. Richmond, VA: MFA.

National Conference of State Legislatures. 2007. State laws on heart attacks, cardiac arrest & defibrillators. www.ncsl.org/programs/health/aed.htm; retrieved Jan. 15, 2008.

YMCA of the USA. 2006. Automated External Defibrillators (AEDs) in YMCAs: A Technical Assistance Paper (2nd edition).

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Shirley Archer, JD, MA

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