Automated External Defibrillators in Fitness Facilities

By Shirley Archer, JD, MA on Apr 23, 2008

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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