Full text of DOI:10.1080/10903120290938292

LAW ENFORCEMENT AGENCY DEFIBRILLATION (LEA-D):
PROCEEDINGS OF THE NATIONAL CENTER FOR EARLY DEFIBRILLATION POLICE AED ISSUES FORUM
Vincent N. Mosesso, Jr., MD, Mary M. Newman, BS, Joseph P. Ornato, MD, Paul M. Paris,
MD, and the National Center for Early Defibrillation Police AED Issues Forum Panelists: Leon
Andersen, MD, Kathryn Brinsfield, MD, Gregory R. Dunnavant, MD, MS, Detective Jay
Frederick, William J. Groh, MD, Deputy Chief Steven Johnston, E. Brooke Lerner, PhD, EMT-
P, George Murphy, EMT-P, I/C, Robert J. Myerburg, MD, Donald G. Rosenberg, MD, Police
Officer Mitchell Savino, EMT-P, Michael R. Sayre, MD, Joseph Sciammarella, MD, Valerie
Schoen, EMT-P, Philip Vargo, EMT-P, Anouk van Alem, MD, and Roger D. White, MD
medical services (EMS) system, cardiopulmonary
INTRODUCTION
resuscitation (CPR), and rapid defibrillation is com-
1
1,12
monly referred to as “the chain of survival.”
Scope of the Problem
Despite scientific confirmation that this chain of sur-
vival provides the optimal treatment for sudden car-
diac arrest, SCA survival rates in the United States
remain dismal. On average, only 7% of SCA victims
1
2
Each year in the United States, 250,000 to 450,000
people collapse in sudden cardiac arrest (SCA); two-
1
thirds arrest outside the hospital. This is more than
the annual number of deaths due to automobile acci-
13
survive. If defibrillation could be delivered more
3
dents, cancer, and HIV combined. In fact, it is more
rapidly, however, survival rates could be much high-
er.
Indeed, animal research and human studies in
supervised cardiac rehabilitation centers indicate that
than the number of people who would die suddenly if
a fully-loaded 747 aircraft crashed every day for a full
year.
An estimated 45–85% of out-of-hospital cardiac
arrest victims present with the reversible cardiac
survival rates can be as high as 90% with immediate
14–17
defibrillation.
Relatively high VF survival rates
4
–7
arrest rhythm of ventricular fibrillation (VF).
The
also have been documented in King County,
speed with which electrical rescue shocks are deliv-
ered to the hearts of these victims correlates directly
with the likelihood of survival: the sooner the heart is
shocked, the more likely the victim is to survive (Fig.
18,19
Washington (34%),
(
in Rochester, Minnesota
20
45%), and in a casino study in Clark County,
Nevada, including Las Vegas (59%). The American
Heart Association estimates that if communities could
21
1
). Moreover, the sooner the heart is shocked, the bet-
8
–10
ter the neurological outcome.
The combination of early access to the emergency
Received February 14, 2002, from the National Center for Early
Defibrillation, University of Pittsburgh, Department of Emergency
Medicine, Pittsburgh, Pennsylvania (VNM, MMN, PMP); and the
Medical College of Virginia, Richmond, Virginia (JPO). Revision
received March 8, 2002; accepted for publication March 12, 2002.
Support for Police AED Issues Forum: National Center for Early
Defibrillation (NCED), The Medtronic Foundation, American Heart
Association. Support for NCED: The Medtronic Foundation, A. S.
Laerdal Foundation, Medtronic Physio-Control, Laerdal Medical
Corporation, Agilent Technologies/Heartstream Operation (now
Philips Medical Systems), Zoll Medical Corporation, EMP
International/Medic First Aid, American Safety & Health Institute,
SurVivaLink Corporation (now Cardiac Science Corporation).
FIGURE 1. Probability of survival from ventricular fibrillation car-
diac arrest based on intervals from collapse to cardiopulmonary
resuscitation (CPR) and defibrillation. (Curves indicate time of ini-
tiation of CPR.) Reproduced with permission from: Valenzuela TD,
Roe DJ, Cretin S, et al. Estimating effectiveness of cardiac arrest
interventions: a logistic regression survival model. Circulation.
1997;96:3308-13.
Address correspondence and reprint requests to: Vincent N.
Mosesso, Jr., MD, National Center for Early Defibrillation,
University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213. e-
mail: <mosessovn@msx.upmc.edu>.
This article is being co-published, with nonsubstantive variation, in
Resuscitation, July 2002.
273

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
•
Sudden cardiac arrest occurs most often in the
2
3
24
home (57% –76% ), followed by public locations,
such as medical clinics or other extended care facil-
ities, work sites, streets and highways, airports,
2
5–29
churches, and event centers.
LEA personnel
often are in the vicinity of these locations.
•
Advances in technology have made it possible for
non-medical personnel to use AEDs quickly and
3
0
safely with a minimum of training. LEA personnel
trained in the use of AEDs demonstrate skill com-
petency levels comparable to those reported among
3
1,32
EMS personnel.
FIGURE 2. Actual and target ventricular fibrillation (VF) survival
• There is a limited time during which defibrillation
can be effective. Reducing the time from collapse to
shock by even 1 or 2 minutes can determine
1
,5,13,15–18,21
15–17
rates.
A = cardiac rehabilitation centers
; B = Casino
2
1
5
Project ; C = Rochester, Minnesota ; D = King County, Washing-
1
8
1
13
ton ; E = target ; and F = U.S. average.
5
,20,33,34
whether or not the victim will survive.
achieve even a 20% survival rate, 50,000 lives could be
saved each year (Fig. 2).
Therefore, it is reasoned, if LEA personnel can reach
and treat victims with AEDs even a few minutes
before EMS arrives, the chances for neurologically
intact survival may improve.
1
Rationale for Law Enforcement Agency
Defibrillation as a Solution
This concept was endorsed in a joint position state-
ment by the International Association of Chiefs of
Police (IACP) and the International Association of Fire
One of the strategies for rapid delivery of defibrilla-
tion in community settings that has been proposed is
the use of automated external defibrillators (AEDs) by
law enforcement agency (LEA) personnel. (We use the
term “law enforcement agency” or “LEA” throughout
this document to refer not only to police officers but
also to other LEA personnel, such as sheriff depart-
ment deputies, state troopers, correctional officers,
treasury police, search and rescue personnel, and
SWAT teams. However, for literary purposes, we
sometimes use the terms “LEA” and “police” inter-
changeably.)
35
Chiefs (IAFC) and further promulgated through
publication of the IACP “Training Key” entitled
Automated External Defibrillators, which outlines rea-
36
sons “why police officers should have AEDs.”
Despite these developments, few law enforcement
agencies provide defibrillation services. A national
survey of state EMS departments determined that less
than 20% of fire and police first-responder agencies
(
fire and police) were in a state of defibrillation readi-
37
ness. A national survey of law enforcement agencies
found that AEDs were used by less than 3% of police
agencies.
The rationale for LEA defibrillation (LEA-D) pro-
grams to supplement traditional EMS is based on the
following principles:
22
NCED Police AED Issues Forum
•
Typically, there are more LEA personnel than EMS
personnel in a given community and they are con-
tinually on patrol throughout the service area,
poised to respond immediately to emergencies.
EMS units often are station-based, fewer in number,
and subject to diversion from the service area to
transport patients to the hospital or provide mutual
aid. Thus, LEA personnel often arrive at the scene
To explore the concept of LEA-D as a strategy for
improving survival from out-of-hospital cardiac arrest
and to formulate a position statement on the issue, the
3
8
National Center for Early Defibrillation (NCED) con-
vened cardiac arrest researchers and law enforcement
agency leaders in January 2001 at the NCED Police
AED Issues Forum (Fig. 3).
The goals of the NCED Police AED Issues Forum
were to: 1) share results and experiences from research
studies and model police AED programs; 2) identify
barriers to police AED use; 3) make recommendations
on ways to overcome these barriers; and 4) improve
the frequency and effectiveness of AED use among
police first responders. Efforts were made to examine
not only scientific research but also the practical expe-
rience of police providers and administrators.
2
0
before EMS personnel.
•
LEA personnel have an established role as
guardians of public safety. Moreover, most serve as
guardians of public health: 81% of police depart-
ments respond to medical emergencies and 50%
provide some level of patient care. Adding defib-
rillation services should greatly enhance care ren-
dered while not requiring significant operational
changes.
2
2
An overview of the problem of sudden cardiac

Mosesso et al. LAW ENFORCEMENT AGENCY DEFIBRILLATION
275
arrest, including published research on early defibril-
lation and the use of automated external defibrillators
RESEARCH REVIEW
(AEDs) by first responders, particularly law enforce-
LEA-D Studies
ment personnel, was presented. This was followed by
a panel discussion that addressed ten key issues: iden-
tification of law enforcement agencies that should pro-
vide AED services; integration of police-AED pro-
grams within the public safety system; dispatch; med-
ical oversight; training; liability; personnel; program
coordination; equipment; and quality.
Rochester, Minnesota
The concept of the provision of defibrillation services
by police officers was introduced in a landmark paper
in 1994 by Roger D. White, MD, and colleagues at the
4
0
Mayo Clinic, in Rochester, Minnesota. Ongoing
results have been described in several subsequent
5
,20,41
Panelists drew from science and practical experi-
ence to examine each issue. Observers were given the
opportunity to comment. Recommendations from the
panel formed the basis for an NCED LEA-D position
papers.
These researchers used an observational
outcome design to describe the effect of adding police
AED capabilities to the existing EMS response system
during a seven-year period beginning in 1990.
Survival rates were comparable whether police
3
9
statement and best practices recommendations.
FIGURE 3. National Center for Early Defibrillation (NCED) Police AED (Automated External Defibrillation) Issues Forum participants and
observers.

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
TABLE 1. Summary of Published Law Enforcement Agency Defibrillation (LEA-D) Studies
Rochester5
Pittsburgh6
Indiana7
Population studied
78,276
38 sq mi
2,060
12
145,000
464,741
Area
46 sq mi
3,152
2,326 sq mi
53-389 (range) 200 (mean)
112
Population density per sq mi
Number of AEDs placed
Defibrillators by sq mi
Defibrillators by population
Total cases
30
0.32 per sq mi
1 per 6,523 pop
246
0.67 per sq mi
1 per 4,833 pop
249
0.05 per sq mi
1 per 4,149 pop
388
Initial rhythm: VF/VT
Call-to-shock interval: EMS first vs. police first
131 (53%)
172 (45%)
180 (46%)
6.7 (2.0–13.2) vs. 5.9
9.4 (±3.9) [n = 52] vs. 8.2
(±3.0) [n = 75]63
11.6 ± 7.8 vs. 6.9 ± 3.9;
p < 0.0001
(3.3–9.1); p = 0.023
Call-to-shock interval: survivors vs. non-survivors 5.6 (2.0–9.6) vs. 6.9
NA
NA
(
2.8–13.2); p < 0.001
Call-to-shock interval: control vs. intervention
Police arrive before EMS
NA
11.8 vs. 8.7 (p < 0.0001)
NA
7%
%
44%
59%
VF survival: shock by EMS first vs. police first
VF survival: control (historical) vs. intervention
41% (30/73) vs. 40% (23/58) 7.4% (6/81) vs. 26.1% (12/46) 10% (16/160) vs. 15% (3/20)
NA 6% vs. 14% (p = 0.1) 7.8% vs. 10.6% (p = 0.38)
AED = automated external defibrillation; VF/VT = ventricular fibrillation; ventricular tachycardia; EMS = emergency medical services.
shocked first (40%; 23/58) or EMS shocked first (41%;
0/73). Further, researchers determined that return of
ed AED training and performance among police offi-
3
cers and found that police performed at a level equiv-
alent or superior to the performance level of emer-
gency medical technicians (EMTs) and firefighters
spontaneous circulation (ROSC) in the field was asso-
ciated with patient survival 97% of the time. Other
important contributions from the Rochester research
include recognition of the need for clock synchroniza-
tion, identification of the “call-to-shock” interval as
the key interval that can be measured objectively and
reliably, and the determination that reducing call-to-
shock intervals by even 1 minute improves survival.
3
1
reported in previous studies. In addition, they
described the importance of developing and monitor-
ing a system to evaluate training, compliance with
4
2
protocol, and efficacy.
Six Counties in Indiana
Researchers from the Krannert Institute of Cardiology,
Indiana University School of Medicine, reviewed the
effects of police AED programs through the Police As
Responder Automated Defibrillation Evaluation
(PARADE) trial conducted in six suburban and rural
Allegheny County, Pennsylvania
At about the same time that the Rochester research
was getting under way, University of Pittsburgh
researchers launched a prospective cohort study with
historical controls to evaluate police AED programs in
seven suburban communities in southern Allegheny
7
counties in Indiana. In this study, historical data were
gathered retrospectively during 1995–1996 and police
AED capabilities were gradually introduced in six
suburban and rural counties from 1997 through 1999.
When police arrived first, call-to-shock intervals were
shortened by 4.8 minutes (p = 0.008). However, police
arrived before EMS in only 6.7 % of cases (26/388).
Consequently, overall survival rates in the study com-
munities did not improve after police were equipped
with AEDs.
The low frequency of first response by police offi-
cers was attributed to many factors: insufficient police
AED coverage for the geographical service area;
responder reluctance associated with psychological
barriers, such as discomfort with the role of AED
provider and a lack of confidence in personal per-
6
County, Pennsylvania. Historical data were retro-
spectively gathered from 1990 and 1991. During the
intervention phase (1992–1995; n = 127), police were
trained and equipped with AEDs. Police arrived
before EMS in 61% of cases and the call-to-shock inter-
val was 3.1 minutes shorter (p < 0.0001). When police
arrived before EMS and administered shocks, VF sur-
vival was 26 % vs. 3% when police arrived first but did
not administer shocks (p = 0.01). Researchers found
that police use of AEDs decreased the time to defibril-
lation and was the only independent predictor of sur-
vival to hospital discharge. There was a trend toward
improved survival among all patients in VF (6% vs.
14%, p = 0.1). The Pittsburgh researchers also evaluat-

Mosesso et al. LAW ENFORCEMENT AGENCY DEFIBRILLATION
277
formance; failure to dispatch police and EMS simulta-
neously; ambiguous, misunderstood, or inconsistently
applied dispatch instructions; lack of formal emer-
gency medical dispatch (EMD) training; prompt EMS
response times; commitment to other law enforcement
duties in progress at the time of the call; and concerns
about personal liability risk.
TABLE 2. Variables Associated with Increased
Likelihood of Survival in Published Law Enforcement
Agency Defibrillation (LEA-D) Studies
Rochester5
Pittsburgh6
Indiana7
Variable*
Call-to-shock interval
ROSC with shocks only
Call-to-scene interval
Bystander CPR
X
X
X
X
X
X
X
X
X
Cincinnati, Ohio
Age
Male gender
A prospective controlled trial conducted in Cincinnati
in 1997–1999 failed to show improvement in hospital
discharge survival rates. The existing EMS system
included paramedic-staffed ambulances and defibril-
lator-equipped fire vehicles in four police districts. In
one of these districts, 33 police cars were equipped
with AEDs and police and fire were dispatched simul-
taneously. Outcomes in the intervention district were
compared with those in the three control districts.
While the addition of police AED capabilities reduced
the mean call-to-shock time by 27 seconds (median
call-to-shock interval 515 seconds in test district, 542
seconds in control districts, p = 0.054), the intervention
Collapse in public location
Use of AEDs by police
X
*ROSC = return of spontaneous circulation; CPR = cardiopulmonary resusci-
tation; AED = automated external defibrillator.
TABLE 3. Annual Incremental Law Enforcement Agency
Defibrillation (LEA-D) Program Costs58
1
. Device(s), divided by the expected life of the device in years
generally about five years)
(
2
. Peripheral equipment (e.g., electrodes, batteries, hand towels,
scissors, exam gloves, pocket masks with one-way valves),
divided by the expected life of the equipment in years
3
4
5
6
. Device maintenance
4
3
was not associated with improved survival. A sur-
vey conducted among 69 police officers toward the
end of the trial determined that while 63% felt ade-
quately trained to use the device, 54% were concerned
about liability risks and 39% were concerned about
. Automated external defibrillator (AED) training
. Incremental salary of program personnel (if applicable)
. Event documentation, including data management equipment
and software
7
. Medical direction and quality assurance costs
. Insurance
4
4
causing injury to patients with the AED.
8
Miami–Dade County, Florida
During a five-month period in 1999, all police officers
in Miami–Dade County were trained and equipped
with AEDs. Police and EMS were dispatched simulta-
neously to potential SCA calls. Police arrived first in
Conclusions from Published LEA-D
Studies
A review of the published LEA-D studies (Rochester,
Pittsburgh, and Indiana) indicates that significant
improvements in survival were achieved in study
communities with higher population density per
square mile. In addition, they suggest that whereas the
provision of CPR predicts survival in semi-rural areas,
AED intervention predicts survival in urban and sub-
urban areas (Table 1). Further, the only variable asso-
ciated with improved survival in all three studies is
the call-to-shock interval (Table 2).
76% of SCA cases (n = 273 cases) in an average of 5.6
minutes. This contrasts with the average EMS
response time of 7.7 minutes. VF survival rates
increased from 9.6% before police-AED intervention
to 18.3% after police-AED intervention.45 Subsequent
data analysis on a larger sample indicates a persisting
survival benefit for patients with shockable rhythms
4
6
since inception of the program.
Amsterdam, The Netherlands
Costs Associated with LEA-D Programs
A two-year randomized controlled trial, ARREST-4,
got under way in Amsterdam in January 2000. It uses
a crossover design in which police with AEDs serve
half the population, while police without AEDs serve
the other half. This treatment allocation is reversed
every four months. Preliminary results suggest that
police arrive at the scene an average of 2.5 minutes
sooner than EMS. Among the 32 patients who were
shocked first by police, VF was converted to an organ-
ized rhythm in 16 (50%), and seven patients (22%) sur-
Costs associated with LEA-D programs frequently are
cited as a deterrent to program implementation (Table
3). However, research suggests defibrillation pro-
4
9
grams are cost-effective. The cost of a first responder
(police or fire) defibrillation program over five years,
for example, ranges from an estimated $4,400 per year
5
0
51
of life saved to $8,000 per year of life saved. This
compares favorably with the cost per year of life saved
considered acceptable for other medical interventions
4
7,48
49
vived to hospital discharge.
($50,000 per quality-adjusted life year). Moreover,

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
TABLE 4. Incremental Cost–Effectiveness of
Reducing Time to Defibrillation by 1.9 Minutes
per Additional Quality-adjusted Life Year (QALY)
ery of care. They acknowledged that turf issues some-
times arise, but agreed these can be overcome if
addressed quickly and tactfully. They recommended
involving EMS from the outset with program plan-
ning and implementation, the development of proto-
cols, the provision of initial and refresher training, and
medical direction. LEA-D protocols should be coordi-
nated with protocols of other emergency response
agencies and should address local transfer proce-
dures. For example, they should consider whether
police should continue treatment, assist EMS, or
depart the scene; whether AED cable adaptors should
be used; and whether EMS should take the AED or
transfer data from the AED.
59
Cost/QALY*
BLS-D (additional EMS units)
Firefighter AED
Lay responder AED
Police AED
$191,100
$63,700
$46,700
$29,000
*
BLS-D = basic life support–defibrillation; EMS = emergency medical servic-
es; AED = automated external defibrillation.
the incremental cost of adding defibrillation services
to established emergency response agencies is rela-
tively small in comparison with the cost of adding
additional units to EMS agencies (Table 4).
Issue 3: Dispatch
Panelists agreed that the dispatch system is critical to
the success of any LEA-D program. They discussed
the importance of emergency medical dispatch (EMD)
training for dispatchers; pre-arrival instructions that
include real-time coaching in CPR and AED tech-
niques; simultaneous dispatch of first responders and
higher-level providers, preferably through central dis-
patching; minimal call processing time; and methods
for identifying the closest unit with a defibrillator,
including utilization of mutual aid responders.
Panelists agreed that LEA-D dispatch protocols
should: be specific and rigorous; identify complaints
that trigger an automatic AED response; avoid over-
or undertriage; be coordinated with protocols of other
response agencies; and be reviewed and updated fre-
quently (Table 5). They also discussed the importance
of recognizing dispatchers as essential members of the
lifesaving team, for example, in program planning
and training and in awards and ceremonies honoring
rescuers who help save a life. Incorporating these
characteristics will require the commitment of dis-
patch center leadership, dedicated personnel time,
and likely additional costs.
ISSUES DISCUSSION
Issue 1: Criteria to Identify Law
Enforcement Agencies That Should
Provide AED Services
Panelists recognized that LEA-D programs have not
been proven to be a universally appropriate strategy
for decreasing time to defibrillation. Further, there are
no known data that predict the proportion of cases in
which police would have to arrive first to make LEA-
D programs effective and cost-effective. Despite this,
panelists agreed survival rates may improve signifi-
cantly in many communities with the implementation
of LEA-D programs. Important research findings that
should be considered are: 1) arriving even 1 or 2 min-
5
utes before EMS can improve survival ; 2) the percent
of time police arrive before EMS is more important
than the mean difference between police and EMS
arrival times; and 3) to maximize survival, the mean
response time (time from dispatch to arrival at scene)
5
2
should be less than 8 minutes. System adjustments
e.g., simultaneous dispatch of police and EMS, specif-
(
ic protocols) may make it possible for law enforcement
agencies to achieve these objectives. Ultimately, adop-
tion of an LEA-D program has to be a local decision
that considers local resources and priorities.
Panelists also agreed that AED use by specialty
police services, such as correctional officers, treasury
police, search and rescue teams, and SWAT teams,
may facilitate more rapid defibrillation than can be
accomplished through EMS alone, in light of restrict-
ed access issues and the potential dangers of work
sites and operational venues.
Issue 4: Medical Oversight
Panelists recognized that medical oversight may be a
new concept for many law enforcement agencies, but
concluded it is essential to ensure optimal patient care.
They concurred that the qualifications of a LEA-D
medical director include physician licensure, commit-
ment, and familiarity with and interest in the prehos-
pital environment, as described elsewhere. The local
EMS medical director should be considered for the
position or consulted for recommendations of other
qualified physicians.
Another suggestion was to appeal to local retired
physicians who have the time and expertise to devote
to the role of LEA-D medical director. The job descrip-
tion for a medical director includes oversight of the
training, development of response and treatment pro-
5
3
Issue 2: Integration of LEA-D Programs
within the Public Safety System
Panelists discussed the need for integration of LEA-D
programs with the EMS system to ensure an organ-
ized, reliable response that results in a seamless deliv-

Mosesso et al. LAW ENFORCEMENT AGENCY DEFIBRILLATION
279
tocols, regular face-to-face meetings with police chiefs
and officers, case review, and follow-up.
TABLE 5. Complaints That Should Trigger Dispatch of
Police with Automated External Defibrillators (AEDs)
60
Medical director compensation depends on local
factors. LEA-D oversight could be assumed by the
local EMS medical director or another government
supported physician with little or no incremental pay-
ment. In smaller communities, physicians may opt to
provide medical direction services on a voluntary
basis. The local hospital may provide support for
physician and staff involvement as a community out-
reach effort. Prospective medical directors should be
aware of potential expenses such as travel and insur-
ance coverage.
Unconsciousness
Chest pain or tightness in chest
Radiating pain, especially in left arm
Unexplained falls with altered mental state or loss of
consciousness
Collapse after exertion
Dizziness in patient over age 35
Not breathing normally
Blow to chest with loss of consciousness
Erratic pulse
Drowning
Electrocution
Asphyxiation
Stroke reported by bystander
Issue 5: Training
Note: A report published after the National Center for Early Defibrillation
6
1,62
(NCED) Police AED Forum
suggests that certain dispatch protocol deter-
Panelists agreed that the quality of AED training
strongly influences the success of LEA-D programs.
They agreed that high-quality programs have these
characteristics in common: 1) a focus on device-specif-
ic, practical skills; 2) course duration based on skills
acquisition and demonstrated competency; 3) training
scenarios customized for local situations, including
specific plans for transfer of care to EMS; 4) use of peer
training; and 5) validated AED training with official
recognition (e.g., course completion certificates) from
minant codes have high “cardiac arrest quotients,” which can help predict
the likelihood that an AED will be needed on scene.
Issue 6: Liability
Research7,43 and experience suggest that concerns
about legal liability risks related to the use of AEDs
are a serious issue for many police departments and
officers. Panelists concluded that LEA-D programs
should recognize these are important concerns that
may dissuade police departments from adopting AED
programs and may delay effective response on the
part of individual police responders.
a
nationally recognized training organization.
Panelists agreed that LEA-D training also should
address fears that AEDs can harm operators or
patients, liability concerns, and proper treatment for
pediatric and non-shock cases. Local EMS agencies
were recognized as a valuable resource for LEA-D
training.
Panelists agreed that LEA-D programs should
include education on the facts surrounding this issue.
First and foremost, AEDs are easy to use and difficult
to misuse. In addition, proving causation of harm
through AED use is difficult, considering the fact that
devices are intended for use in individuals who are
already clinically dead. Further, state and federal
Good Samaritan legislation protects individuals who
render emergency medical assistance, including treat-
ment with an AED, in good faith. (Note: This protec-
tion does not always extend to professionals who are
rendering assistance as part of their professional
duties, and as such it is prudent to examine applicable
laws and regulations.) Finally, case law favors AED
deployment, raises the question of liability risks asso-
ciated with failure to provide defibrillation services,
and has found that Good Samaritan legislation implic-
While there are no data to confirm the ideal frequen-
cy of refresher training, panelists recommended that at
least initially retraining should occur on a quarterly
basis to ensure skill maintenance and foster confi-
dence. Some recommended conducting brief sessions
at regular monthly meetings that review key police
department policies and practices (roll call). Others
recommended even more frequent reviews using one-
on-one practice and/or computer-based refresher
training. In general, panelists agreed that short, fre-
quent review sessions are more helpful than longer
infrequent sessions. After the program has been in
place for several years, longer retraining intervals may
be adequate. Panelists agreed that a standard approach
to refresher LEA-D training would be helpful.
Panelists recommended that devices include or
enhance real-time coaching capabilities. They noted
that the American Society for Law Enforcement
Training (ASLET) could potentially play a key role in
developing and promulgating LEA-D training.
Finally, panelists recommended that AED training
become a core component of basic training in police
academies and considered a basic skill for all law
enforcement personnel.
5
4
itly authorizes AED use by laypersons.
Issue 7: Personnel
Panelists discussed the psychological issues that may
affect LEA personnel, particularly disagreement or
uneasiness with the role of medical provider and AED
use. They recommended validating and addressing
these feelings and perceptions through: 1) discussions
with personnel about their perceptions and concerns;
2) surveys conducted among personnel before and
after introduction of the program (in which respon-

280
PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
TABLE 6. Ten Attributes of Successful Law
Enforcement Agency Defibrillation (LEA-D) Programs39
Issue 9: Equipment
There are several AED models on the market that have
Food and Drug Administration (FDA) clearance.
Panelists did not endorse any particular device, wave-
form, or brand. Panelists agreed that funding for
equipment has been a major impediment to program
implementation and further acknowledged that the
costs of training and administration of the program
may exceed the cost of devices themselves. However,
they viewed device costs, in comparison with other
1
. The ability to respond quickly and reliably to medical
emergencies
2. A supportive medical response culture within the LEA
3
. Strong champions in the community and within the LEA who
serve as program advocates
4
5
6
7
8
9
. Integration with the emergency medical services (EMS) system
. An effective, coordinated dispatch system
. A proactive, “hands-on” medical director
. A designated program coordinator
55
LEA equipment, as relatively minor. Further, they
. Effective, competency-based initial and refresher training
advised that to minimize costs, police departments
consider group purchasing of devices and mainte-
nance agreements.
. Familiarity with applicable laws and regulations and attention
to liability concerns
1
0. An effective Continuous Quality Improvement (CQI) program,
including written policies and procedures and data collection
and analysis
With regard to device selection, panelists agreed it is
not essential for devices selected by law enforcement
agencies to be compatible with devices used by local
EMS systems; however, similarity of devices may sim-
plify training, data collection, and administration.
Human factors (e.g., the degree to which the device is
user-friendly and intuitive) also should be considered.
Panelists advised that if agencies decide to adopt
AED programs and officers use take-home cars, it is
ideal to equip each officer—not each patrol zone—to
maximize community coverage. Case reports in which
off-duty officers resuscitated SCA victims support this
dents can remain anonymous) to determine percep-
tions and concerns and address opportunities for pro-
gram enhancement; 3) the provision of psychological
support after cardiac arrest responses through critical
incident stress debriefing; 4) prompt follow-up by the
medical director and program administrator with
AED providers following each case in which resusci-
tation was attempted; 5) initial and refresher training
that results in sustained competence and confidence;
and 6) positive feedback and celebration of successes.
Panelists also recommended that program leaders
avoid setting unrealistically high expectations for
improved survival.
5
6
strategy.
Panelists also recommended the following design
enhancements: real-time video coaching on CPR and
AED techniques; more efficient data recording and
transfer capabilities, including a standardized ECG
data storage format; automatic time synchronization;
incorporation of communications capabilities that
enable interface with other public safety agencies;
capabilities to treat pediatric patients; simplified pad
placement (e.g., incorporating electrodes into a vest);
and greater uniformity of device design.
Panelists acknowledged that workforce and union
issues can affect LEA-D programs. In some locations,
the questions of compensation for training time and
expanded roles, and the potential for discord between
chiefs and officers may need to be addressed.
Issue 8: Program Coordination
Issue 10: Quality
Panelists agreed that for an LEA-D program to be
effective, it is essential to have a program coordinator
who serves as a liaison between the medical director,
the police chief and police officers, and who has spe-
cific managerial duties. The medical director and pro-
gram coordinator should work together to develop
policies and procedures for the LEA-D program.
These should address: initial and refresher training
requirements, patient care protocols, dispatch proto-
cols, synchronization of timepieces, device deploy-
ment, device maintenance checks, device storage in
extreme weather conditions, supply checks (e.g., spare
batteries and electrodes), data collection and reports,
case review, critical incident stress debriefing, and
outreach efforts to stimulate public awareness of the
LEA-D program and the need for bystander interven-
tion and layperson CPR training.
To ensure the quality of the LEA-D program, panelists
recommended: regular protocol review; regular
refresher training and documentation of competency;
scheduled, documented equipment maintenance
checks; prompt review of each cardiac arrest in the
service area to determine whether police responded,
whether they arrived first, whether they used the
AED, whether they used the AED properly, whether
other actions such as CPR were conducted properly,
and whether the AED functioned properly; positive,
constructive feedback and corrective action as needed;
and data collection and review to evaluate the impact
of the program on survival and to monitor trends.
Police AED Issues Forum panelists emphasized the
need for data collection to monitor the effect of local
LEA-D programs on survival from sudden cardiac
arrest.

Mosesso et al. LAW ENFORCEMENT AGENCY DEFIBRILLATION
281
Update. Dallas, TX: American Heart Association, 2001.
SUMMARY
4
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survival of ventricular fibrillation in out-of-hospital cardiac
arrest patients in Sweden. Resuscitation. 2000;44:7-17.
. White RD, Hankins DG, Bugliosi TF, et al. Seven years’ experi-
ence with early defibrillation by police and paramedics in an
emergency medical services system. Resuscitation. 1998;39:145-
Why does LEA-D intervention seem to work in some
systems but not others? Panelists agreed that some
factors that delay rapid access to treatment, such as
long travel distances in rural areas, may represent
insurmountable barriers. Other factors, however, may
be addressed more readily. These include: absence of
a medical response culture, discomfort with the role of
medical intervention, insecurity with the use of med-
ical devices, a lack of proactive medical direction,
infrequent refresher training, and dependence on EMS
intervention. Panelists agreed that successful LEA-D
5
5
1.
6
. Mosesso VN, Davis EA, Auble TE, Paris PM, Yealy DM. Use of
automated external defibrillators by police officers for treatment
of out-of-hospital cardiac arrest. Ann Emerg Med. 1998;32:200-
7.
7. Groh WJ, Newman MM, Beal PE, et al. Limited response to car-
diac arrest by police equipped with automated external defib-
rillators: lack of survival benefit in suburban and rural Indiana
—the Police As Responder Automated Defibrillation Evaluation
3
9
programs possess ten key attributes (Table 6).
(PARADE). Acad Emerg Med. 2001;8:324-30.
In the end, the goal remains “early” defibrillation,
not “police” defibrillation. It does not matter whether
the rescuer wears a blue uniform—or any uniform, for
that matter—so long as the defibrillator reaches the
victim quickly. If LEA personnel routinely arrive at
medical emergencies after other emergency respon-
ders or after 8 minutes have elapsed from the time of
collapse, an LEA-D program will be unlikely to pro-
vide added value. Similarly, if police frequently arrive
first, but the department is unwilling or unable to cul-
tivate the attributes of successful LEA-D programs,
efforts to improve survival may not be realized.
8. Yakaitis RW, Ewy GA, Otto CW, et al. Influence of time and
therapy on ventricular defibrillation in dogs. Crit Care Med.
1
980;8:157-63.
9
. Stiell IG, Wells GA, Field BJ, et al. Improved out-of-hospital car-
diac arrest survival through the inexpensive optimization of an
existing defibrillation program: OPALS Study phase II. Ontario
Prehospital Advanced Life Support. JAMA. 1999;281:1175-81.
10. Weaver WD, Copass MK, Bufi D, et al. Improved neurologic
recovery and survival after early defibrillation. Circulation.
1
984;69:943-8.
1
1. Newman MM. Chain of Survival concept takes hold. J Emerg
Med Serv. 1989;14(8):11-3.
2. Cummins RO, Ornato J, Thies W, et al. Improving survival from
sudden cardiac arrest: the “chain of survival” concept.
Circulation. 1991;83:1832-47.
3. Callaway C. Improving neurologic outcomes after out-of-hospi-
tal cardiac arrest. Prehosp Emerg Care. 1997;1:45-57.
4. Kouwenhoven WB. The development of the defibrillator. Ann
Intern Med. 1969;71:449-58.
15. Haskell WL. Cardiovascular complications during exercise
training of cardiac patients. Circulation. 1978;57:920-4.
6. Hossack, KF, Hartwig R. Cardiac arrest associated with super-
vised cardiac rehabilitation. J Card Rehabil. 1982;2:402-8.
7. VanCamp SP, Peterson RA. Cardiovascular complications of
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1160-3.
8. Eisenberg M, Horwood B, Cummins R, et al. Cardiac arrest and
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9. Eisenberg ME, Mengert TJ. Cardiac resuscitation. N Engl J Med.
1
In most communities, however, LEA-D programs
have tremendous lifesaving potential and are well
1
4
2,57
worth the investment of time and resources.
Law
1
enforcement agencies considering adoption of AED
programs should review the frequency with which
police arrive first at medical emergencies and LEA
response intervals to determine whether AED pro-
grams might help improve survival in their communi-
ties. It is time for law enforcement agency defibrilla-
tion to become the rule, not the exception.
1
1
1
1
2
The authors thank The Medtronic Foundation and the American
Heart Association for providing funding to help support this meet-
ing and acknowledge Joan Mellor of The Medtronic Foundation
Heart Rescue Program for her vision and dedication to this initia-
tive. They acknowledge Mike Bell and Mark Decker of the
American Heart Association for assisting with meeting analysis.
They also thank the following individuals for reviewing the manu-
script: Robert Bass, MD, Mike Bell, Grace Day, Mark Decker, Alex
Denogean, Darrell Isaac, Cliff King, Joan Mellor, René Mitchell, RN,
John Nealon, Robert Niskanen, Joseph Pahlow, James K. Russell,
PhD, William Smirles, EMT-P, and Robert Swor, DO. Finally, the
authors thank meeting planner, Kathleen Stage-Kern, CMP, and
administrative coordinator, Chrysia Melnyk, for their important
contributions to the success of this meeting.
2
001;344;1304-13.
0. White RD. Patient outcomes following defibrillation with a low
energy biphasic truncated exponential waveform in out-of-hos-
pital cardiac arrest. Resuscitation. 2001;49:9-14.
1. Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid
defibrillation by security officers after cardiac arrest in casinos.
N Engl J Med. 2000;17:1206-9.
2. Alonso-Serra, HM, Delbridge TR, Auble TE, et al. Law enforce-
ment agencies and out-of-hospital emergency care. Ann Emerg
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3. Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of car-
diopulmonary resuscitation prior to defibrillation in patients
with out-of-hospital ventricular fibrillation. JAMA. 1999;281:
2
2
2
1
182-8.
2
4. Litwin PE, Eisenberg MS, Hallstrom AP, Cummins RO.
Location of collapse and its effect on survival from cardiac
arrest. Ann Emerg Med. 1987;16:669-72.
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