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Emergency AED Readiness in American Schools

Emergency AED Readiness in American Schools

December 23, 2020 | Last Updated: July 27, 2021
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Abstract

Avive Solutions Inc. wanted to evaluate the quality, level of penetration, and expected effectiveness of Automated External Defibrillators (AED) deployed in US schools. We sought to determine if there exists a difference in AED deployment based on socio-economic factors and the school population. We anticipated US schools with high nurse-to-school ratios, as well as Title I schools, to be less likely than other schools to have AED units and cardiac emergency response plans as nurses are spread thin, and the addition of a defibrillator program may not be feasible through funding from lower-income districts (and may not be a priority in a Title I budget).

Avive received survey responses from 178 of 1,000 US school nurses regarding their AED preparedness and found that there were significant differences in AED penetration across all schools. Aside from informing us of which type of schools have AED units, our survey served to give us insights in the form of management best practices. The nurse survey intended to illuminate the gaps in US high school AED protocol and offer methods, awareness, and education to improve protocol weaknesses. The most prevalent AED issue is that many schools fall short in operating a proper AED program because of a lack of education on the subject. 61% of nurses expressed that they would like more education on the topic of AEDs, 21% revealed that their AED is housed behind locked doors, and 18% don’t have/don’t know of AED emergency plans. Nurses admitted that the schools they preside over need more education and preparedness. With poor emergency response and maintenance plans, high schools in the US risk liability and lives lost.

Survey Methodology

To obtain a diverse collection of responses, Avive built an initial contact list of 20 randomly-selected nurses from each state (1,000 in total), offering an even geographic distribution of the survey’s “population.” Each nurse received an introductory email asking for their help and opinion by completing Avive’s survey. To ensure an adequate number of responses, we timed our delivery such that our initial email was spread over two months, with approximately 125 new emails sent each week. Emails were sent on weekdays and during predicted work hours (approximately 9 AM to 5 PM local time).

Of the 1,000 emails sent, our email system rejected 0.6% (6) emails based on formatting or other technical errors. Of the remaining 994 email prospects, 3.9% (39) were marked as invalid, 2.9% (29) were rejected and not delivered—leaving us with 918 delivered emails in our population.

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Note: Rejected and invalid emails occur for reasons, including, but not limited to:

  • Data-entry errors
  • Restrictions from recipients on receiving external emails
  • Emails that are no longer valid due to a change in employment circumstances (i.e. nurses who are no longer working for a given school)
  • Anti-spam software

Nurses who replied to our email or who completed our anonymous survey were removed from our follow-up queue, and those who didn’t reply or complete the survey were sent a reminder email five days after the first email. If a nurse replied to the reminder, they were removed from the queue. Those who didn’t were sent another reminder until we received a reply or had sent four total emails.

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The longer a survey is, the fewer responses a surveyor will generally obtain, so we had to be selective in choosing questions while balancing against the desire to cover a broad swath of topics.

Before beginning the survey, our understanding was that school districts, state laws, and public vs. private vs. charter schools, vary in nurse-to-school ratios, thus we elected to ask the population questions regarding the number of schools for which they’re responsible. Moreover, asking this question would allow for the comparison of results as a function of nurse-to-school ratios.

The survey began by asking all respondents to classify themselves into the following segments: population demographics, private school, public school, charter school, and yielded the following results:

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Observations & Results

Whether mandated by law or not, not all schools have AED units. Avive hoped that the survey results would be impartial regardless of a school’s ownership of an AED so that we could draw useful insights about the differences between the two. For instance, why don’t some schools have AEDs? We also sought to understand common challenges with school AED programs and identify areas to improve AED management and maintenance.

Accessibility Obstacles

Restricting individuals from accessing and using an AED in an emergency impacts emergency response time and can even be cause for a lawsuit if the AED is unavailable and responders are unable to provide aid. Therefore, AEDs should always be easily and readily accessible on school campuses

AEDs are designed to be easy to use, even by lay-people with little training. A common misconception is that there is a formal “AED certification.” This is false. You do not need a certification to operate an AED.

41% of nurses showed that there is a limited number of people on campus who are allowed to use an AED in an emergency. These findings indicate that there needs to be improved by the schools and districts to expand on who is allowed to operate a school’s AED.

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Restricting individuals from accessing and using an AED in an emergency impacts emergency response time and can even be cause for a lawsuit if the AED is unavailable and responders are unable to provide aid. Therefore, AEDs should always be easily and readily accessible on school campuses

AEDs are designed to be easy to use, even by lay-people with little training. A common misconception is that there is a formal “AED certification.” This is false. You do not need a certification to operate an AED.

41% of nurses showed that there is a limited number of people on campus who are allowed to use an AED in an emergency. These findings indicate that there needs to be improved by the schools and districts to expand on who is allowed to operate a school’s AED.

AED_readiness_in_Schools-Does-your-school-have-a-cardiac-emergency-response-plan?

Reasons for these location related obstacles include:

  • Campus size/not enough AEDs
  • Floor levels
  • Access card to enter campus buildings
  • AEDs locked behind doors
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31% of nurses have no knowledge of or are unsure about cardiac emergency response plans.

A school nurse is an integral part of the first aid response team and it is vital that nurses, staff, and students are familiar with the response plan in event of a cardiac emergency. While the minority of school nurses surveyed were unaware of cardiac emergency response plans on campus, greater awareness and preparedness among school nurses will only help save lives.

In a cardiac emergency, who is going to ask for your certification card? Take action. Call. Push. Shock

Martha Lopez-Anderson.

Executive Director of Parent Heart Watch

“If the response time is longer than 4 minutes, we purchase another unit. Schools with multiple buildings on the school campus, have an AED unit for each building.”

Anonymous Nurse

“Do you lock up your fire extinguisher? So why would you lock up your AED?”

Martha Lopez-Anderson

Executive Director of Parent Heart Watch

Dislike

“Our doors are locked so that only staff with access cards, codes, or badges can get inside.”

Anonymous Nurse

New Hampshire

“Actually unlocking the cabinet with a code during a stressful event. If the wrong code is applied it won’t open.”

Anonymous Nurse

New Hampshire

Community Size

While no conclusions could be drawn based on the number of AEDs per school based on the size of the community in which the school is located, and despite our expectations going into the survey, we did observe that the age of AED units varied between community sizes.

Community TypePopulation
Rural < 20,000
Large Town20,000 - 10,000
City100,001 - 300,000
Very Large City300,000 - 1,000,000
Metropolis>1,000,000

Number of AEDs by Community Type

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The results indicate that rural communities have new AED units less frequently than very large cities and metropolises. 3.6% of rural communities had AEDs less than a year old and 9.1% had them between 1-3 years, versus 0% and 28.6% for large cities and 0% and 25% for metropolises, respectively. This may indicate that schools in rural communities generally began acquiring AED units later in the AED deployment lifecycle than schools in larger cities.

Overall, we were surprised at how long schools report having had AED units. AEDs on the market today have electrode pads and batteries that expire at intervals of approximately 2-5 years depending on the make and model of AED unit and approximately 7-8 year product warranties, implying that aged devices have had to go through more than one disposable accessory replacement cycle and may have expired warranty.

A lack of attention to the replacement cycle is a primary cause of AED failure, so it is essential that AED program managers pay acute attention to the age and replacement cycles of their devices.

AED_readiness_in_Schools-Community-Type-by-Nurse-Deployment
AED_readiness_in_Schools-How-would-you-describe-the-primary-community-in-which-you-work?

Education

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Results show that only 35% of students are made aware of AED locations. This is a huge issue as students make up the majority of a school campus’ population. If a victim were to fall in the bathroom, or locker room, another student would most likely have to be the first responder.

More surprisingly, responses “administration,” “all teachers,” and “me,” should all be 100%. It is especially concerning that 10% of the surveyed nurse population were not made aware of the location of their AED(s), despite the fact that they’re likely the first to be contacted during a case of suspected cardiac arrest.

Someone might not realize there are multiple AEDs and go to the one further away.

Anonymous Nurse

AED_readiness_in_Schools-Who-is-allowed-to-use-the-AED(s)?

Education on AEDs, especially its location, cannot be stressed enough. Schools are training students for the future. Simple emergency training and education can teach these students to be the new generation of lifesavers. This education will go beyond the classroom setting and these students can educate and help others outside of school.

61% of nurses expressed their need for more education on the topic of AEDs on campus.

Nurses mentioned that they wanted:

  • Emergency cardiac arrest drills
  • AED and CPR training
  • Written AED emergency protocol
  • Education on cardiac arrest and AEDs
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We cannot be in all places at all times. The biggest “obstacle” would be the travel time between the location of the incident and the nurses. If someone else is trained to use the AED, they know they can access it.

Anonymous Nurse.

Delaware

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Make sure EVERYONE knows where they are located.

Anonymous Nurse.

Nurses cited that 40% of teachers, parents, and students know that “you can’t hurt someone with an AED” showing that 60% of teachers, parents, and students don’t know this. This is where education is essential. AEDs evaluate the state of a victim and will make a decision itself on whether or not it is safe to shock an individual. Responders shouldn’t be fearful of hurting a victim.

It should be known that the use of an AED requires very little training.

Financing

75% of nurses cited price as the reason for not having an AED. AEDs are notoriously expensive but to prioritize a defibrillator in a school’s budget by just a little can yield invaluable results. Learn how to get AED funding.

Our data indicate a very high level of AED penetration (98%); much higher than we deem realistic.

There are several reasons that this may have occurred:

  • Nurses with AED programs are (rightfully) proud of their programs and willing to share their information, whereas those without AEDs, prefer to share the fact that they don’t have lifesaving programs
  • The subject, body, and tone of our emails may have implied we exclusively sought feedback from AED owners, instead of anyone with an opinion
  • Regardless of anonymity, nurses without AEDs may not have had the authority to share that their school doesn’t have one
  • Some may have viewed our survey as a “sales pitch” and, by asserting that they have an AED program, they’re sharing that “there’s no sales opportunity” at their school
AED_readiness_in_Schools-Why don't you have AEDs at your school?
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The school board is responsible for providing and maintaining the AED. I worry that until we have an event I will not see any activity moving forward to obtaining one. I would like to see it required by law!

Anonymous Nurse.

Liability

AEDs are expensive and it is understandable that a school would want to protect them by locking them away from students. However, in doing so, schools run the risk of litigation. Liability attorney Steve Tannenbaum explains how Good Samaritan protection from liability is granted only when AEDs are used or attempted to be used:

“Rules are made and laws are enacted in order to protect the safety of the public. When these rules and laws are violated (like motor vehicle operational laws) people get hurt. When people are injured due to the negligence or fault or others, liability is created, and the people or parties who caused the harm to become legally liable for all the damage that they have caused.

The same logic applies to defibrillators; laws have been enacted across the country mandating the presence of AEDs in many public locations, particularly at schools. They are placed there, by law, in order to protect our students during school hours and school activities. When they are not deployed under these circumstances, a Florida court has recently held that a school can incur liability if a trial jury finds that school employees breached the duty of reasonable care owed to students by failing to use state mandated AEDs.

In the State of Florida, Courts have held, as in most states, that there is a special relationship between schools and students based on the fact that the school functions, at least partially, in the place of parents during the school day and during school-sponsored activities. The Florida Supreme Court ruled in the case of Limones v. School District of Lee County, et al. that due to the fact that state law required the presence of the students at school and at school related activities, combined with the fact that Florida law required the presence of an AED on school premises, that the school where Abel Limones suffered a cardiac arrest during a high school soccer game owed him a duty of supervision and to act with reasonable care under the circumstances.

More specifically, the court ruled that the school district owed him a duty to take appropriate post cardiac arrest efforts to avoid or mitigate further aggravation of his injury (cardiac arrest).

The court sent the case back to trial for a jury to determine whether the actions of the school’s employees in failing to use the school’s AED satisfied or breached the duty of reasonable care owed.

Just as importantly, the Court held that the district, as acquirers of the AED, are not immune from liability due to the mere fact that they had purchased and made available an AED which had not been used. Rather, they are entitled to immunity from the harm that may result only when an AED is actually used or attempted to be used.

As a result of the brain damage which Abel sustained, due to a failure of the school to use its AED which was present on the field (Abel was first defibrillated approximately 23 minutes after his cardiac arrest by first responders) the school district will potentially be liable for a verdict well in excess of $10 million as a result of the costs necessary to properly maintain him for the rest of his life.

The lesson to be learned here is that liability for failure to use an AED can only be incurred when the law is violated and someone gets hurt as a result. Good Samaritan protection from liability will only be applicable when an AED is actually used or attempted to be used. Our children deserve the full protection of the law in order to protect their health and well-being.

Cases like this are not only tragic but can be cause for litigation.

Lawsuits can also originate from expired AEDs.

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A lot of schools thought they were ready. They thought being prepared consisted of just calling 911. A 14-year-old football player collapsed, the coaches turned him on his side, poured cold water on him and called 911. That’s it. No CPR. The school was required by state law to have an AED. And they had one. It wasn’t used so he died.

Martha Lopez-Anderson.

Executive Director of Parent Heart Watch

Maintenance

20% of nurses shared that they are unsure of the age of their AED.

A lack of awareness about aging and expired AED parts is dangerous because AED requires regular maintenance. AED maintenance is incredibly important as expired pads may mean that the electricity-conducting gel on the pads has dried and the resuscitating electrodes can’t be properly applied to a patient’s chest to assess his or her heart rhythm and deliver a shock (if necessary). Furthermore, outdated batteries mean that the AED won’t even turn on.

It is surprising that so few nurses know the age of their school’s AED as monthly checks are telling of this information, which may imply that routine checks aren’t being properly performed. Additionally, not knowing the age of a unit can mean that the AED is outdated.

AED_readiness_in_Schools-Approximately-how-long-have-you-had-the-AEDs?
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There is an AED Coordinator for each building site/school with an AED unit. The units are visibly checked daily and monthly documented electronically.

Anonymous Nurse

Electrode pads generally expire in about two years, and batteries (depending onthe frequency of AED usage) can expire anytime between 2-5 years. Many AED manufacturers also provide indemnification coverage with the purchase of a defibrillator and proper ongoing management to protect the defibrillator owner and operator from lawsuits, but as an AED’s accessories expire, this protection can expire with it. An unmaintained, outdated AED likely provides the same medical benefits as not having an AED in the first place—and it can even increase the likelihood of a cause for legal action.

A majority of nurses who preside over only Title I schools or some Title I schools reported having AEDs over 7 years old.

Schools that have no Title I funding reported having AEDs between the ages of 1-3 years. This is not the majority of the data, but it shows that schools are making initiatives in deploying AEDs.

*Note: Predictions for AED expirations are estimates. Consult your AED’s user manual for exact expiration dates.

AED_readiness_in_Schools-Age-of-AEDs-by-School-Type

Nurse-to-school Responsibilities

As the nurse-to-school ratio increased from one nurse: one school to one nurse: multiple schools, the percentage of nurses that didn’t have or were unsure of an emergency cardiac plan decreased. With more schools to preside over, a nurse must be more familiar with the emergency response plan. Because of their campus rotation, nurses are less familiar with the nuances of each campus and thus must be well versed in emergency response plans to make up for lost time because of unfamiliarity with a campus.

AED_readiness_in_Schools-Nurse-to-school-responsibility-of-nurses-unsure
AED_readiness_in_Schools-Number-of-AEDs-by-Nurse-to-school-Responsibility

Public vs. Private vs. Charter Schools*

*Written fields were requested for “other” and we learned that 1.2% (2) responses were for “charter” schools.

Private and public schools both had the majority of AED ages greater than 7 years.

As for emergency planning, 100% of private schools have cardiac emergency response plans (CERPs) and a majority of public schools do too. 68.2% for all schools is higher than what Avive anticipated, which is great to see, but there is still work to be done. Thankfully, implementing an emergency response plan is easily attainable, not to mention worthwhile.

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Does your school have an emergency response plan?

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Title 1 Schools

Title 1 schools receive supplemental funds to assist schools with the highest concentration of poverty to meet school educational goals. A Title 1 school may have students that come from families with high incomes, but this federal designation is for the school based on the surrounding area. It is not indicative of the entire school’s population but allows for interesting comparisons.

It can be difficult to compare results as many schools have a combination of high and low-income earning families. To objectively categorize our findings, it was most prudent to determine if there are differences between Title 1 schools and all others.

Title 1 schools receive supplemental funds to assist schools with the highest concentration of poverty to meet school educational goals. A Title 1 school may have students that come from families with high incomes, but this federal designation is for the school based on the surrounding area. It is not indicative of the entire school’s population but allows for interesting comparisons.

It can be difficult to compare results as many schools have a combination of high and low-income earning families. To objectively categorize our findings, it was most prudent to determine if there are differences between Title 1 schools and all others.

AED_readiness_in_Schools-Number-of-AEDs-by-School-type
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Parental involvement in Title I schools are less than others. That’s a reality. Some schools will have up to 12 AEDs. A Title I school might have one or two. Maybe not even one.

Martha Lopez-Anderson.

Executive Director of Parent Heart Watch

What you can do

So, what can you do? Awareness and education head the objective of making every school a heart-safe environment. Nurses collectively proved their schools’ proactivity by showing that only 6.7% of schools have AEDs available during school hours. 72% estimate that it would take no more than 2-5 minutes to properly respond to a cardiac arrest. However, more still needs to be done.

Thankfully, several issues that the nurse survey showed were issues with practical and achievable solutions.

During the survey, nurses suggested methods for improving the AED program:

  • Unlocked AED units
  • Maps to locate an AED on campus
  • More financial allocation to purchase an AED

Our survey showed that nurses are spread thinly across schools and districts. This information is not new. Nurses cannot be in all places at once, but they can still implement proper AED protocol. AED rescue drills and response plans, in addition to fire and earthquake drills, can be implemented into a school.

Resources

  • Parent Heart Watch created a program to model the importance of AEDs and CERPs in schools to prevent sudden cardiac death and to familiarize administrators, educators, school nurses, coaches, and parents about the role they can play to champion prevention in their school community.
  • Their health flyer introduces the basic steps needed to operate an effective CERP team.
  • Check out How to Fundraise for an AED.
  • Properly educating a student body on AEDs and cardiac arrest will give them a vital understanding of its significance. To remove AEDs from behind locked doors and to stop AED usage from being just administration or nurses will maximize first aid response in a life-threatening situation. Education not only teaches the rising generation how to be lifesavers but also reduces the risk of liability.
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They must achieve program milestones before we give them an AED. We go through a webinar and provide educational printed materials and videos, etc. to educate the school

Martha Lopez-Anderson.

Executive Director of Parent Heart Watch

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The Top 6 Ways to Drive AED Awareness at Schools

Conclusion

  1. Our survey results did not indicate a difference between Title I and other schools. Title I schools presented as much, and more, AED penetration as other schools. We are concerned that it is not truly representative, but the results given by these nurses remain insightful.
  2. Nurses who were responsible for several schools instead of one showed to be increasingly familiar with CERPs. Though they are spread thinly across schools, we are glad to see reports of emergency preparedness.
  3. Lastly, all nurses regardless of where they worked (Title I, not Title I, private school, public school) showed that a majority of the schools they presided over had AEDs that were at least 7 years old.

Note: Results were heavily skewed towards those with existing programs, and given the differences in AED deployment between those who replied and those who didn’t, our survey results should not be misconstrued as an estimate of the national level of AED penetration in schools.