PS ITEM #1
October 25,2012
Worksession
MEMORANDUM
October 23,2012
TO:
FROM:
SUBJECT:
Public Safety Committee
Amanda Mihill, Legislative
Attorne~
Worksession:
Bill 26-12, Swimming Pools - Defibrillators
Bill 26-12, Swimming Pools - Defibrillators, sponsored by Councilmembers Leventhal, Riemer,
Rice, Navarro, Andrews, EIrich and Floreen, was introduced on September 11, 2012. A public
hearing was held on October 16 at which 2 speakers testified in support of Bill 26-12 (see
testimony on ©13).
Bill 26-12 would require certain swimming pools to have an automated external defibrillator
available on the premises. See ©7 for a memorandum from the sponsors explaining the purpose
behind Bill 26-12.
Background
State Law
The Maryland Pubic Access Automated External Defibrillator Program,
1
which is
administered by the Maryland Institute for Emergency Medical Services Systems (MIEMSS)
requires facilities with AEDs to meet certain state requirements and be certified by the State
EMS Board (see law on
©
17). This law provides facilities that are in compliance with the law
immunity from civil liability for an act or omissions in the provision of AEDs. Additionally, the
state law provides individuals who use AEDs with protection from civil liability if the person is
acting in good faith to a victim, the assistance is provided in a reasonably prudent manner, and
the AED is provided without fee. As the letter from MIEMSS notes, swimming pools that are
affected by the bill would be required to comply with this statute
16)?
MIEMSS Report
In 2007, the Generally Assembly passed, and the Governor signed, Senate
Bill 742, Swimming Pools - Automated External Defibrillator Programs
Study. SB 742
required MIEMSS to study whether automated external defibrillators should be provided on-site
at swimming pools in the State, including which pools should be required to provide AEDs,
whether AED-trained individuals should be required on-site, and the safety of AEDs at pools.
Maryland Code,
Education
Article,
§
13-517.
2
The MIEMSS AED application packet can be found at:
1
http://www.lniernss.org/homciLinkCl ick.aspx?liIeticket= WkD2 fi2ZtPY%3 D&tabid=8 5&m id=495.
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Additionally, SB 742 required MIEMSS to recommend other locations that AEDs should be
required. The report (on ©22) concludes:
• The effectiveness of defibrillation in a given public access program is directly related to
the percentage of cardiac arrests that are witnessed and how often and how quickly the
rescuers are able to obtain, correctly apply, and activate the AED.
• The cost-effectiveness of a public access program is related to several factors, including
the likelihood of a cardiac arrest occurring at the location and the likelihood that the
victim will survive.
• Requiring AEDs at every pool was not supported in the 2007 report.
• Voluntary placement of AEDs at pools, especially larger ones, as well as participation in
public access programs should be encouraged.
Action in other jurisdictions Both Anne Arundel and Queen Anne's counties have enacted
laws to require public and semi-public pools to have an AED on-site.
FiscallEconomic Impact Statements The Fiscal and Economic Impact Statements are attached
on ©8. According to Executive Staffs analysis, all pools that the County owns or operates
currently have AEDs on-site. If Bill 26-12 is enacted, the Department of Health and Human
Services (DHHS), which currently inspects and licenses pools in the County, estimates that 70
hours per year would be required for ongoing inspections (and additional staff time during the
first year of implementation for education and training activities). DHHS can absorb these
additional duties with existing staff, but notes that it may reduce the ability to complete other
inspections.
Executive staff estimates that Bill 26-12 will have a modest economic effect on the
owners/operators of affected pools. Costs that will be incurred include the defibrillator, cost of
replacing certain parts (batteries, pads), and training. Executive staff estimates that the cost to
affected pools that do not currently have defibrillators on-site will be approximately $2,200.
Issues for Committee Discussion
Which agency should enforce Bill
26-12?
As introduced, the County Fire and Rescue Service
would enforce Bill 26-12 (FRS enforces the defibrillator requirement in health club facilities).
DHHS currently inspects and licenses all pools (other than pools associated with a single family
detached house). The Fiscal Impact Statement assumes DHHS will enforce the bill. Council staff
recommendation: require DHHS to enforce Bill 26-12.
Councilmember Leventhal amendment A proponent of Bill 26-12, Ms. Debbie Neagle-Freed,
tragically lost her son, Connor Freed, due to drowning and cardiac arrest at a community pool
13). Ms. Neagle-Freed strongly feels that if an AED was available for use, it could have saved
Connor's life and now advocates for pools to have an AED on-site. Councilmember Leventhal
intends to offer an amendment to title the law, "Connor's Law."
2
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This packet contains:
Bill 26-12
Legislative Request Report
Sponsor memorandum
Fiscal and Economic Impact Statements
Testimony
MIEMSS cover letter correspondence
State law
MIEMSS Report
Leventhal amendment
Circle
#
1
6
7
8
13
16
17
22
41
F:\LA W\BILLS\1226 Swimming Pools - Defibrillators\Public Hearing Memo.Doc
3
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Bill No.
26-12
Concerning: Swimming
Pools
Defibrillators
Revised:
9/5/2012
Draft No. _1_
Introduced:
September 11,2012
Expires:
lVIarch 11, 2014
Enacted: _ _ _ _ _ _ _ _ __
Executive: _ _ _ _ _ _ _ __
Effective: _ _ _ _ _ _ _ _ __
Sunset Date: _ _ _ _,---_ _ __
Ch. _ _, Laws of Mont.
COUNTY COUNCIL
FOR MONTGOMERY COUNTY, MARYLAND
By: Councilmembers Leventhal, Riemer, Rice, Navarro, Andrews, EIrich and Floreen
AN
ACT to:
(1)
(2)
require certain swimming pools to have an automated external defibrillator
available on the premises under certain circumstances; and
generally amend the law concerning swimming pools.
By amending
Montgomery County Code
Chapter 51, Swimming Pools
Section 51-1
By adding
Chapter 51, Swimming Pools
Section 51-16A
Boldface
Underlining
[Single boldface brackets]
Double underlining
[[Double boldface brackets]]
* * *
Heading or defined term.
Added to existing law by original bill.
Deletedfrom existing law by original bill.
Added by amendment.
Deletedfrom existing law or the bill by amendment.
Existing law unaffected by bill.
The County Council for Montgomery County, Maryland approves the following Act:
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BILL No. 26-12
1
Sec. 1. Chapter 51 is amended
by
amending Section 51-1 and adding
Section 51-19A:
51-1. Definitions.
In this Chapter, the following words have the following meanings:
[(a)]
Approving authority[:
The] means the Director of the Department of
Health and Human Services or the Director's designee.
Automated external defibrillator
means
f!
portable electronic device that
2
3
4
5
6
7
8
9
provides an electric shock to the heart in order to reestablish normal
contraction rhythms in
f!
heart having dangerous arrhythmia or that is in
cardiac arrest.
[(b)]
Automatic pool cover[:
A] means
f!
mechanical device that completely
covers the swimming pool surface automatically when activated, and meets
the requirements of a power safety cover established by the American Society
for Testing and Materials ..
[(c)]
Lifeguard[:
A] means
f!
person who:
(1)
is at least 15 years old; and
10
11
12
13
14
15
16
17
18
19
20
21
(2) has a valid lifeguard certificate from the American Red Cross, the
Young Men's Christian Association, or a comparable program
approved by the Director of the Department of Health and
Human Services.
[(d)]
Oi-vner[:
Any] means any person, cooperative, association, partnership,
firm, corporation, public agency, or authorized agent of any of them, excluding
a pool management company, under whose authority a swimming pool or
private spa is being constructed, remodeled, reconstructed, or operated. For the
purposes of serving notices of violation of this chapter, the person present at
the swimming pool or private spa and charged with its operation is an agent of
the owner.
22
23
24
25
26
27
o
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BILL
No. 26-12
28
29
[(e)]
Pool management company[:
Any] means any person, cooperative,
association, partnership, firm, or corporation, excluding a pool operator, who
is responsible by contract or other agreement with the owner of a public
swimming pool for the operation of the public swimming pool, including [but
not limited to one or more of the following]:
[(i)
Assuring]
30
31
32
33
34
35
ill
assuring compliance with all operating standards set forth
in this Chapter and all rules and regulations promulgated hereunder;
[(ii)
Providing]
m
providing for the physical maintenance, supplies, and
36
37
38
personnel as required by this Chapter and all rules and regulations
promulgated hereunder; and
[(iii) Obtaining]
ill
obtaining all necessary permits and licenses.
[(t)]
Pool operator[:
Any] means any person in possession of a valid county
39
40
pool operator's license who is in the immediate control of the operation of a
public swimming pool.
[(g)]
Private spar:
Any] means any outdoor bathing structure that is:
(1)
a self-contained unit in which all control, water heating, and
water circulating equipment is an integral part of the unit;
(2)
(3)
built on the grounds of a single-family private residence;
used solely by the owner, immediate family, tenants, and guests;
and
(4)
not used for swimming, diving, or wading.
41
42
43
44
45
46
47
48
49
50
51
52
53
54
[(h)]
Private swimmingpool[:
Any] means any swimming pool that is:
(1)
(2)
built on the grounds of a single-family private residence; and
used solely by the owner, immediate family, tenants, and guests.
[(i)]
Public spar:
Any] means any public swimming pool that is:
lei)
Intended]
ill
intended for public recreational and therapeutic
uses other than swimming, diving, or wading; and
0-
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BILL
No. 26-12
55
56
57
[(ii)
Is]
ill
is not drained, cleaned, or refilled for each user.
(0)]
Public swimming poo/[:
A] means
f!
swimming pool, except a private
swimming pool, which is intended to be used collectively by numbers of
persons for swimming, diving, wading, or recreational bathing.
[(k)]
Spa guard[:
58
59
60
An]
means
an individual currently certified
In
cardiopulmonary resuscitation (CPR).
61
62
63
64
65
66
[(1)]
Swimming poo/[:
Any] means any artificial structure, basin, chamber, or
tank, except a private spa, either above or below ground, which is used or
intended to be used for the primary purpose of swimming, diving, wading, or
recreational bathing. Swimming pool includes all appurtenant equipment,
structures, and facilities located within a common enclosure. A unit used
in
conjunction with the private practice of a physician or physical therapist is not
a swimming pool.
67
68
69
51-16A. Defibrillators.
{ill
Every public swimming pool must have available at all times when the
pool is open at least one automated external defibrillator in good
working order and at least one staff member who is trained in its use.
70
71
72
(Q)
ill
This Section is not intended to impose any civil liability, or
relieve any person from civil liability, regarding the presence or
use
Q;h
or failure to use, any automated external defibrillator,
except as expressly provided in paragraph
Q1
73
74
75
76
77
ill
An owner or employee of
f!
public swimming pool is not liable in
connection with the use or nonuse of an automated external
defibrillator -'. unless:
(A)
the pool does not have an automated external defibrillator
available as this Section requires; or
78
79
80
(3)­
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BILL
No.
26-12
81
82
.an
@
an employee has acted with gross negligence or engaged in
willful or wanton misconduct.
83
84
85
86
87
88
Any violation of this Section is
class C civil violation. The County
Attorney or any affected person may file an action in
court with
jurisdiction to enjoin repeated violations ofthis Section.
W
The County Fire and Rescue Service must investigate each complaint
alleging
violation of this Section and take appropriate action,
including issuing
citation when compliance cannot be obtained
otherwise. The Department of Health and Human Services may, if
requested, assist the Service in enforcing this Section.
89
90
91
Approved:
92
Roger Berliner, President, County Council
Date
93
94
Approved:
Isiah Leggett, County Executive
Date
95
This is a correct copy o/Council action.
96
Linda M. Lauer, Clerk ofthe Council
Date
f:llaw\bills\1226 swimming pools - defibrillatorslbill1.doc
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LEGISLATIVE REQUEST REPORT
Bill 26-12
Swimming Pools
~
Defibrillators
DESCRIPTION:
Bill
26~12
would require certain swimming pools to have an
automated external defibrillator available on the premises under
certain circumstances.
Automated external defibrillators are currently not required on site at
swimming pools that are open to the public.
To require swimming pools, other than private swimming pools, to
have an automated external defibrillator on site.
Fire and Rescue Service; Department of Health and Human Services
To be requested.
T? be requested.
To be requested.
To be researched.
Amanda Mihill, Legislative Attorney, 240-777-7815
To be researched.
PROBLEM:
GOALS AND
OBJECTIVES:
COORDINATION:
FISCAL IMPACT:
ECONOMIC
IMPACT:
EVALUATION:
EXPERIENCE
ELSEWHERE:
SOURCE OF
INFORMATION:
APPLICATION
WITHIN
MUNICIPALITIES:
PENALTIES:
Class C violation.
f:\law\bills\1226 swimming pools - defibrillators\legislative request report.doc
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MONTGOMERY COUNTY COUNCIL
ROCKVILLE, MARYLAND
MEMORANDUM
September 6,2012
To:
Councilmembers
From: George Leventhal and Hans Riemer
Re:
Bill 26-12, Swimming Pools - Defibrillators
We are introducing a bill which is attached to this memorandum. The bill mandates that a
defibrillator become standard equipment at all semi-public pools in Montgomery County
(i.e. swim clubs). The county already mandates that a defibrillator be on site for all
county operated swim facilities. In 2004 the Council passed Bill 22-04 which requires
commercial fitness centers in Montgomery County to have a defibrillator on the
premlses.
The need for this legislation is illustrated by a tragic event that occurred in Anne Arundel
County on June 22,2006. A 5 year old boy, Connor Freed, drowned beneath an empty
lifeguard chair, at a country club, in five feet of water. A patron of the pool spotted
Connor's lifeless body and pulled him out of the water. Another patron began performing
cardiopulmonary resuscitation (CPR) as he threw up water. Once 911 was called, they
questioned, "Is there a defibrillator there?" The response: "Yes. But we are not allowed
to use it." Connor went into cardiac arrest in the ambulance on the way to the hospital.
The importance of having a defibrillator on site is because it needs to be used within the
first five minutes when someone is experiencing cardiac arrest. Paramedics usually can
take five minutes or longer to arrive on scene. Defibrillators save lives. A person's
chances of survival are reduced by 7 to 10 percent with every minute that passes without
CPR and defibrillation. Few attempts at resuscitation succeed after 10 minutes.! Similar
legislation has been enacted in Queen Anne's and Anne Arundel counties. All Maryland
lifeguards are now required by law to be CPR certified as well as trained on the use of a
defibrillator.
1 "Cardiac Arrest," from the American Heart Association Web site,
http://www .arnericanheart. org!presenter .jhtml?id entifi er=448I
STELLA
B.
WERNER COUNCIL OFFICE BUILDING·
100
MARYLAND AVENUe: • ROCKVILLE, MARYLAND
20850
2401777-7900
• TTY
240/777-79
14 • FAX
240/777-7989
WWW.MONTGOMERYCOUNTYMD.GOV
g
PRINTED ON RECYCLED PAPER
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-
ROCKVILLE, MARYLAND
AH
c...c
': L
r
LL..
070435
MEMORANDUM
October 9,2012
TO:
FROM:
Roger
Berliner, President,
County Council
Jennifer
A.
Hu
Joseph F.
BeacU;i~ctor,
Department of Finance
~irector,
Office
of
Management and Budget
SUBJECT:
Council
Bill 26-12 ­
Swimming Pools -
Defibrillators
Attached please find the fiscal and eoonomic impact statements
for
the above­
referenced
legislation.
JAH:dl
Attachment
c: Kathleen Boucher, Assistant
Chief
Administrative Officer
Lisa Austin, Offices
of the County Executive
Joy
Nurmi, Special Assistant to the County Executive
Patrick Lacefield, Director, Public
Information
Office
Gabriel
Albomo~
Department
of
Recreation
Uma Ahluwalia,
Department of
Health and Human Services
Michael Coveyau, Department of
Finance
'
David Platt.
Department
of
Finance
Alex
Espinosa, Office of Management and Budget
Amy
Wilson, Office
ofManagement and Budget
Deborah
Lambert,
Office
of
Management
and Budget
Naeem Mia, Office of Management and Budget
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Fiscal Impact Statement
Council BiI126-12 - Swimming Pools - Defibrillators
1. Legislative Summary
Bill 26-12
would require certain
swimming
pools to have
an
automated
external
defibrillator
available on the
premises
under certain circumstances. All County-owned or -operated
pools
are
currently
in
compliance and
are
not affected by the proposed bill.
2. An estimate of changes
in
County revenues and expenditur& regardless of whether
the revenues or expenditures are assumed
in
the recommended or approved budget.
Includes source of information, assumptions, and methodologies used.
The
proposed bill
will
have no impact on County revenues or expenditures.
All
County­
owned or -operated pools
are
in compliance.
3. Revenue and expenditure estimates covering at least the next 6 fIScal years.
The
proposed bill
will
have no impact on County revenues or expenditures.
4.
An
actuarial analysis through the entire amortization period for each bill that would
affect retiree pension or group insurance
costs~
Not applicable.
This
bill does not
affect
retiree pension or group insurance costs.
5. Later actions that may affect future revenue and expenditures
if
the bill authorizes
future spending.
The bill does not authorize future spending.
6. An estimate ofthe staff time needed to implement the bill.
The
Department of Recreation reports that no
staff
time
is
required to implement
the
bill.
The
Department ofHealth
and
Human Services (DIlliS) reports the following: if
inspectors are required only to check for presence ofdefibri11ator and MIEMSS
registration
status, DHHS
estimates an additional
70
hours per year is required after the
bill takes full effect for .ongoing inspection.
In
the
first
year of implementation, additional staff time is required to address non­
compliance and training/education activities· a
tola!
of
160
hours ofstaff time is needed
to handle these functions.
7. An explanation of how the addition of new staff responsibilities would affect other
duties.
The
Department of Recreation
will
not incur any additional
staff
responsibilities.
DHHS
estimates
it
can
absorb
its
additional duties
by
current Environmental Health Regulatory
Services staff.
However, DHHS notes that
any
additional time devoted to this new responsibility may
reduce the ability to complete the to,OOO
+
mandated inspections per year.
In
FY12,
I
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DHHS'
existing
staff resources completed approximately 75% of currently mandated
inspections.
.
8. An
estimate of costs
wben
an
additional appropriation
is
needed.
Not applicable.
9. A description
of any
variable that could affect revenue and cost estimates.
It
is
difficult
to
estimate how many complaints would be logged, but DHHS staff would
likely have
to
make a
separate visit
to
the facility to investigate each complaint.
10.
Ranges
of revenue or expenditures
tbat
are uncertain or difficult to project.
Not applicable. The bill
has
no impact on County revenues or expenditures.
11.
If
a
bill
is
likely
to
have
no
fIScal
impact, why that
is
tbe case.
Not applicable.
12.
Other fiscal
impacts
or comments.
None.
13. The fonowing contributed to and concurred with this
analysis:
Robin Riley, Depintment ofRecreation
C1ark Beil, Licensure and Regulatory Services, Department of Health
&
Human Services
Pat Brennan, Department of Health
&
Hwnan Services
Deborah Lambert, Office of Management
&
Budget
Naeem Mia., Office of Management
&
Budget
J
o
er A. H
s, DIrector
of Management and Budget
2
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Economic Impact Statement
Council Bill
26-12
Swimming Pools - Defibrillators
Background:
This
proposed legislation requires certain swimming pools to have
an
automated external
defibrillator available on the premises under certain circumstances and generally amends
the law concerning swimming pools.
I. The
sources of information, assumptions, and methodologies
used.
a.
Source of infonnation:
i.
Montgomery County Department of Recreation
(REC)
ii.
Montgomery County Department of
Fire
and Rescue Service (FRS)
iii. Maryland Institute for Emergency and Medical Services System
(MlESS)
b. Assumptions:
i.
Average cost for a defibrillator: ...................
$1.200.00
it
Expected life for the defibrillator (years): ..................
S
iii.
Replacement costs for pads: ...........................
$75.00
iv. Average life of batteries (years): ............ _
................ 3
v. Replacement cost for batteries: ,....................
$200.00
vi.
Average life of pads (years): .................................. 3
vii.
Average cost for training per staff: ................... $13.45
vili. Average cost for certification per staff: ..............
$17.20
ix. Average number of personnel per
pool: ....................
4
x. Training cycle every two years
xi. One extra set of batteries
c. Methodologies used:
Not applicable
2. A description of any variable that could affect the economic impact estimates.
Cost of defibrillator
Cost of replacement batteries
Cost of replacement pads
Cost of training and certification
Number of pool staff that require training and certification
Number of swilTlIIrlng pools required to install a defibrillator
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3. The Bill's positive or negative effect,
if
any on employment, spending, saving.
investment, incomes, and property values in the County.
The bilI will have a modest economic effect on the operators/owners of the swimming
pools. The effect is based on the cost of the defibrillator. the cost of replacing the
batteries and pads, and the cost to train and certify the users of the equipment.
The
total economic effect is the number of ,swimming pools required to install a
defibrillator times the
costs.
Based on information provided by
REe,
FRS, and MIEMSS; the cost of a
defibrillator ranges from $500 to $2,500. However, according to FRS, the average
cost of defibrillators currently in use js $1,200. The batteries are assumed to have
a
life of 3 years with a total cost of $200.00 and Automated External Defibrillator
(ABO)
regul~tions
require an extra set of batteries. The pads are assumed
to
have a
life of 3 years with a total cost of $75.00. Finally, the operator of the defibrillator
must
be
trained and certified in the use of the equipment.
Assuming the operating life of the defibrillator is 5 years and the average cost of
those currently in use, the total cost per swimming pool is estimated to
be
approximately $2,200. Since
there
are approximately 526 swimming pools in the
County, the grand total of the investment would
be
approximately $1,167,000.
That amount assumes that all swimming pools would be required to install a
defibrillator and that
all
staff would
be
trained and certified. However, there are some
facilities that currently have such equipment and a number of pool staff have been
trained and certified. Therefore, the
total
investment cost of $1,167,000 would be the
maximum investment cost to the swimming pool operators/owners.
4.
If
a Bill
is
likely to have no economic impact, why is that the case?
The Bill will have a very modest economic effect on each of the swimming pool
operators/owners.
5. The following contributed to and concurred with this analysis: David Platt and Mike
Coveyoll. Finance
ach. Director
panrnentofFinance
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(
MONTGOMERY COUNTY TESTIMONY
OCTOBER 16
TH ,
2012
My name is Debbie Neagle-Freed and I am Connor Freed's mother and
president of the Connor Cares Foundation. On June 22nd, 2006, at a
local country club, Connor drowned beneath an empty lifeguard chair in
five feet of water. A patron of the pool spotted Connor's lifeless body
and pulled him out of the water. Another patron began performing CPR
as he threw up water. Once 911 was called, they questioned, "Is there a
defibrillator there?" The response: "Yes. But we are not allowed to use
it." Connor went into cardiac arrest in the ambulance on the way to the
hospital. We strongly feel that a simple defibrillator would have saved
his life. Unfortunately, in 2006, Maryland lifeguards only had to be CPR
certified and were not trained on the use of an AED. The American Red
Cross now requires all lifeguards in the state of Maryland to be CPR
certified as well as trained on how to use a defibrillator.
Anne Arundel County passed 'Connor's Law' on July 6
th ,
2012, and
within a couple weeks, a young boy who nearly drowned was aided
back to life with the help of an AED and CPR. It is crucial to have an AED
on site and accessible for lifeguards and patrons because if used within
the first five minutes, a person in sudden cardiac arrest have up to a
90% survival rate (With CPR alone, it's less than 35%). Paramedics can
take up to 10 minutes or longer to get to a scene and by then, it's often
too late with an outcome of death or permanent brain damage.
J
would
l~ke
to thank the Montgomery County
councilmemb~rs
for
JntrQ~ucing
this important life-saving bill. I sincerely hope that
Montgomery County becomes the third county in Maryland to
'Connor/~
J.aw'. Thank you for
yo~r
time.
pas~
@
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Hello, my name is Jeremy Gruber. Retired Fire Rescue Captain and Paramedic from MCFRS where I
worked for over 20 years. I am also a Registered Respiratory Therapist who has practiced medicine in
our community hospitals; also I am the creator/founder of a company called Rescue One which provides
CPR and AED Training and manages thousands of AED programs.
With over 30 years of experience in emergency services and health care I have dealt with numerous
cardiac arrests in and out of hospitals. There is no question in my mind and the clinical experience that I
possess that early CPR and Defibrillation makes all the difference between life and death. I could
personally give you hundreds of accounts of where this has made a difference.
One such account occurred several months ago at my local gym in Olney when a fellow gym member
collapsed in a scheduled fitness class. During the rescue 911 was called immediately along with CPR by
fellow classmates. The AED was gotten and put in to use and before Emergency units arrived the AED
had shocked the victim several times correcting his lethal arrhythmia. Also several weeks ago a teenager
at Catonsville High school was saved by one of my devices while attending class. CPR was begun and the
AED brought to the victim. After one shock her hearts arrhythmia was reset to a pumping heart with a
pulse.
I am here today in support of legislation to require AED units at all public and semi public swimming
pools.
Every year approximately 1/2 million people die from Sudden Cardiac Arrest (SCA), the silent killer. SCA
is one of the leading causes of death in industrial countries. SCA is most often caused by an electrical
malfunction of the heart called ventricular fibrillation (VF) in which the electrical signals that normally
induce a regular, coordinated heartbeat suddenly go chaotic, causing the heart to abruptly stop
pumping blood effectively. The victim stops breathing and has no detectable pulse. Without proper
intervention, death can occur within minutes. Along with CPR the best treatment to restore an effective
heart rhythm is with defibrillation;
Automated External Defibrillators (AEDs) are life-saving devices and are easy to use for those with little
medical knowledge. People unfamiliar with the device often can listen to the voice prompts and aid in a
rescue. It's a simple matter of opening or turning on the AED, attaching the pads to the victim, and
following voice prompts. The device is able to diagnose the heart problem, and if it's a treatable one, the
AED will deliver one or more shocks to restart a normal heartbeat. The best chance for survival is
immediate CPR and for an electrical shock to be delivered to the heart using an AED.
Time is critical for 100% recovery. Why you can't wait for help:
• Only 5-10% SCA victims survive nationwide
• Providing early access to defibrillation and CPR is key to survival and most critical first step
• For every minute that defibrillation is delayed, the victim's chance of survival decreases by
seven to ten percent
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• The victim suffers irreversible brain damage (due to lack of oxygen) within four to six minutes
after sudden cardiac arrest, after ten minutes, very few victims can survive
• Waiting for EMS results in a 5-7% survival rate
• Survival rates of over 50% can be achieved where early defibrillation programs have been
established
SCA can happen anytime, anywhere to anybody at any age WITHOUT any warnings or symptoms. It
causes more deaths than house fires, AIDS, firearms, prostate and breast cancer and automobile
accidents, COMBINED. Surviving a SCA is mostly dependent on how quickly a victim is defibrillated.
An AED is no different than a smoke Detector, air bag, fire extinguisher or life preserver. When the
devices are needed they are needed at that very moment that there is a need.
Since the legislation went into effect requiring gyms to have AED units on site numerous lives have been
saved. Five Gyms that I have personally provided CPR training and AED units to have had successful
resuscitations with those individuals alive and fully functioning as citizens and tax payers.
Through the creation of Rescue one, we have trained tens of thousands of people in the use of an AED
and CPR and First Aid Training, and provided over ten thousand AEDs through all walks of life and
business. I hear from individuals and companies and the government on somewhat of a daily basis in
reference to the lives saved by the AEDs and training. I cannot tell you how gratifying that is, but more
can be done. This is why I am here today.
I would encourage the members of the county council to not only legislate the placement of AED units
at pools but to take it to the next level and require them in all county buildings, including ALL Schools
and large places of assembly. This should also be part of the Fire and building codes requiring units to be
placed in new construction of certain sizes and assembly.
I want to thank you for taking the time in taking up this life saving legislation and hope you will pass this
and consider even more to make Montgomery county the leader in public safety.
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State of Maryland
Maryland
Institute for
Emergency Medical
Services Systems
653 West Ptal! Street
Baltimore, Maryland
21201-1536
September 20, 2012
IWauin
0
'A1nlle.
j
G(}I'emur
The Honorable Roger Berliner
President, Montgomery County Council
Stella B. Werner Council Office Building
100 Maryland Avenue
Rockville, Maryland 20850
Re: Bill 26-12: Swimming Pools-Defibrillators
Dear Councilman Berliner and Members of the Montgomery County Council:
The Maryland Institute for Emergency Medical Services Systems (MIEMSS) is the State
agency that administers Maryland's Public Access Automated External Defibrillator
(AED) program in accordance with the Annotated Code of Maryland, Education Article
§
13-517. The statute requires non-healthcare facilities that locate AEDs on the premises
to meet certain requirements, including registration with MIEMSS. MIEMSS issues a
certificate valid for three years to facilities that meet the requirements. The statute
provides registered facilities in compliance with the statutory requirements with
immunity from civil liability for acts or omissions in the provision of automated external
defibrillation.
In the event Bill 26-12 passes, the pools will be required to meet the requirements of the
above named statute. Enclosed are copies of the statute, regulations, and an AED
Application Packet for your information.
Please feel free to contact Lisa Myers, MIEMSS Director of Cardiac and Special
Programs at lmyers@miemss.org or 410-706-4740 if you have any questions about the
Maryland AED program and requirements for participation.
DOllald
L.
DeVries.
it..
Esq.
Chairman
Emergency!V/edicu/
Serl-'ic£!s
BOllrd
Roherl R, Bass. MD
Ext?clJtit'e Dil't;('tor
4JO-706-5074
FAX 4JO-706-4768
7ra
~
Robert R. Bass, MD,
Cc:
Amanda Mihill, Legislative Attorney
Enclosures (3)
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Page I
LexisNexis®
1 of I DOCUMENT
Annotated Code of Maryland
Copyright 2012 by Matthew Bender and Company, Inc., a member of the LexisNexis Group
All rights reserved.
***
Current through all Chapters Effective October
1,2012,
of the 2012 General Assembly Regular Session, First
Special Session, and Second Special Session.
***
***
Annotations through August 18,2012
***
EDUCATION
DIVISION III. HIGHER EDUCATION
TITLE 13. UNIVERSITY OF MARYLAND -- GENERAL PROVISIONS
SUBTITLE 5. EMERGENCY MEDICAL SERVICES
GO TO MARYLAND STATUTES ARCHIVE DIRECTORY
Md EDUCATION Code Ann.
§
13-517
(2012)
§
13-517. Automated External Defibrillator Program
(a) Definitions. -­
(1) In this section the following words have the meanings indicated.
(2) "Automated external defibrillator (AED)" means a medical heart monitor and defibrillator device that:
(i) Is cleared for market by the federal Food and Drug Administration;
(ii) Recognizes the presence or absence of ventricular fibrillation or rapid ventricular tachycardia;
(iii) Determines, without intervention by an operator, whether defibrillation should be performed;
(iv) On determining that defibrillation should be performed, automatically charges; and
(v) 1. Requires operator intervention to deliver the electrical impulse; or
2. Automatically continues with delivery of electrical impulse.
(3) "Certificate" means a certificate issued by the EMS Board to a registered facility.
(4) "Facility" means an agency, association, corporation, firm, partnership, or other entity.
(5) "Jurisdictional emergency medical services operational program" means the institution, agency, corporation,
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Page 2
Md. EDUCATION Code Ann. § 13-517
or other entity that has been approved by the EMS Board to provide oversight of emergency medical services for each
of the local government and State and federal emergency medical services programs.
(6) "Program" means the Public Access Automated External Defibrillator Program.
(7) "Regional administrator" means the individual employed by the Institute as regional administrator in each
EMS region.
(8) "Regional council" means an EMS advisory body as created by the Code of Maryland Regulations 30.05.
(9) "Regional council AED committee" means a committee appointed by the regional council consisting of:
(i) The regional medical director;
(ii)
The regional administrator; and
(iii) Three or more individuals with knowledge of and expertise in AEDs.
(IO) "Registered facility" means an organization, business association, agency, or other entity that meets the
requirements of the EMS Board for registering with the Program.
(b) Established; purpose. -­
(I) There is a Public Access Automated External Defibrillator Program.
(2) The purpose of the Program is to coordinate an effective statewide publiIc access defibrillation program.
(3) The Program shall be administered by the EMS Board.
(c) Powers of EMS Board. -- The EMS Board may:
(1) Adopt regulations for the administration of the Program;
(2) Issue and renew certificates to facilities that meet the requirements of this section;
(3) Deny, suspend, revoke, or refuse to renew the certificate ofa registered facility for failure to meet the
requirements of this section;
(4) Approve educational and training programs required under this section that:
(i)
Are conducted by any private or public entity;
(ii)
Include training in cardiopulmonary resuscitation and automated external defibrillation; and
(iii) May include courses from nationally recognized entities such as the American Heart Association, the
American Red Cross, and the National Safety Council;
(5) Approve the protocol for the use of an AED; and
(6) Delegate to the Institute any portion of its authority under this section.
(d) Facility certification required. -­
(I) Each facility that desires to make automated external defibrillation available shall possess a valid certificate
from the EMS Board.
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Page 3
Md. EDUCA nON Code Ann. §
13-517
(2) This subsection does not apply to:
(i) Ajurisdictional emergency medical services operational program;
(ii) A licensed commercial ambulance service;
(iii) A health care facility as defined in
§
19-114
ojthe Health
-
General Article;
or
(iv) A place of business for health care practitioners who are licensed as dentists under Title 4 of the Health
Occupations Article or as physicians under Title
14
of the Health Occupations Article and are authorized to use an AED
in accordance with that license.
(e) Facility certification -- Requirements. -- To qualify for a certificate a facility shall:
(1)
Comply with the written protocol approved by the EMS Board for the use of an AED which includes
notification of the emergency medical services system through the use ofthe
911
universal emergency access number as
soon as possible on the use of an AED;
(2) Have established automated external defibrillator maintenance, placement, operation, reporting, and quality
improvement procedures as required by the EMS Board;
(3) Maintain each AED and all related equipment and supplies in accordance with the standards established by
the device manufacturer and the federal Food and Drug Administration; and
(4) Ensure that each individual who is expected to operate an AED for the registered facility has successfully
completed an educational training course and refresher training as required by the EMS Board.
(t)
Report of use of AED. -- A registered facility shall report the use of an AED to the Institute for review by the
regional council AED committee.
(g) Report of use of AED -- Procedures. -- A facility that desires to establish or renew a certificate shall:
(I) Submit an application on the form that the EMS Board requires; and
(2) Meet the requirements under this section.
(h) Certificate -- Contents. -­
(I)
The EMS Board shall issue a new,or a renewed certificate to a facility that meets the requirements of this
section.
(2) Each certificate shall include:
(i) The type of certificate;
(ii) The full name and address of the facility;
(iii) A unique identification number; and
(iv) The dates of issuance and expiration of the certificate.
(3) A certificate is valid for 3 years.
(i) Cease and desist orders. -- The EMS Board may issue a cease and desist order or obtain injunctive relief if a
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Page 4
Md. EDUCA nON Code Ann.
§
13-517
facility makes automated external defibrillation available in violation of this section.
0)
Immunities. -­
(I) In addition to any other immunities available under statutory or common law, a registered facility is not civilly
liable for any act or omission in the provision of automated external defibrillation if the registered facility:
(i)
Has satisfied the requirements for making automated external defibrillation available under this section; and
(ii) Possesses a valid certificate at the time of the act or omission.
(2) In addition to any other immunities available under statutory or common law, a member of the regional
council AED committee is not civilly liable for any act or omission in the provision of automated external defibrillation.
(3) In addition to any other immunities available under statutory or common law, an individual is not civilly
liable for any act or omission if:
(i)
The individual is acting in good faith while rendering automated external defibrillation to a person who is a
victim or reasonably believed by the individual to be a victim of a sudden cardiac arrest;
(ii)
The assistance or aid is provided in a reasonably prudent manner; and
(iii) The automated external defibrillation is provided without fee or other compensation.
(4) The immunities in this subsection are not available if the conduct of the registered facility or an individual
amounts to gross negligence, willful or wanton misconduct, or intentionally tortious conduct.
(5) This subsection does not affect, and may not be construed as affecting, any immunities from civil or criminal
liability or defenses established by any other provision of the Code or by common law to which a registered facility, a
member of the regional council AED committee, or an individual may be entitled.
(k) Opportunity for hearing. -­
(I) A registered facility aggrieved by a decision of the Institute acting under the delegated authority of the EMS
Board under this section shall be afforded an opportunity for a hearing before the EMS Board.
(2) A registered facility aggrieved by a decision of the EMS Board under this section shall be afforded an
opportunity for a hearing in accordance with Title 10, Subtitle 2 of the State Government Article.
HISTORY:
1999, ch. 167; ch. 702, § 5; 2000, ch. 61, § I; 2001, ch. 29, § 1; 2005, ch. 413; 2008, chs. 593, 596, 597.
NOTES:
EFFECT OF AMENDMENTS. --Chapter 593, Acts 2008, effective October 1,2008, rewrote the section.
Chapters 596 and 597, Acts 2008, effective October 1,2008, made identical changes. Each reenacted (a)(l), (a)(3),
and (m)(5) [(j)(5)] without change; deleted (m)(3)(iv); and in (m)(4) ((j)(4)] added "or an individual".
EDITOR'S NOTE. --Chapters 593,596, and 597, Acts 2008 all amended (m). None of the chapters referred to the
others. Chapter 593 redesignated the subsections following repeals and additions of subsections. The changes by chs.
596 and 597 to (m) appear in
0).
In addition, chs. 596 and 597 deleted (j)(3)(iv); thus the amendment to this
subsubparagraph by ch. 593 is superseded. The amendments to (j)(4) have been blended to give effect to all.
BILL REVIEW LETTER. --Chapters 593, 596 and 597, Acts 2008, (Senate Bill 570, House Bill 1134, and Senate Bill
579) were approved for constitutionality and legal sufficiency, and altered individual immunity from civil liability for
providing automated external defibrillation. Chapter 593 renames the Program with the purpose of coordinating
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Page 5
Md. EDUCATION Code Ann.
§
\3-517
effective statewide public access program. The other bills repeal certain existing requirements to retain immunity and
provided that immunities are not available if the conduct of the individual amounted to gross negligence, willful or
wanton misconduct, or intentional tortious conduct.
It
is recommended that the bills' provisions be read together and
given effect with the exception of
§
13-517(m)(3) ofthe Education Article.
If, as a matter of policy, effect is to be given
to the repeal of conditions under which an individual is immune from civil liability as enacted by HB 1134 and SB 579,
these bills should be signed after SB 570; SB 570 was signed first as Chapter 593. (Letter of the Attorney General dated
April!7,2008.)
LexisNexis 50 State Surveys, Legislation & Regulations
Nongovernmental Ambulance
&
Emergency Services
UNIVERSITY OF BALTIMORE LAW REVIEW. --For article, "Gross, Reckless, Wanton, and Indifferent: Gross
Negligence in Maryland Civil Law," see
30
U.
Bait.
L.
Rev.
1
(2000).
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Report to the Maryland General Assem bly
Regarding the Placement of
Automated External Defibrillators
SB742 (Chapter 349) 2007
The Mary land Institute for Emergency Medical Services Systems (MIEMSS)
Robert R. Bass, M.D.
Executive Director
December 2007
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Table of Contents
Background ................................................................................................ 3
Executive Summary .......................................................................................4
Introduction.................................................................................................6
Public Access Defibrillation ..............................................................................6
Maryland Public Access Defibrillation .................................................................8
Public Policy Development. .............................................................................9
Cardiac Arrest at Community Pools - Special Considerations ...................................... 13
Defibrillators at Pools - Safety Issues .................................................................l3
Conclusions and Recommendations ................................................................... 14
Study Limitations ........................................................................................ 15
Table I ..................................................................................................... 17
References ................................................................................................ 18
. Appendix A: AED Task Force & Meeting Attendees
Appendix B: Maryland AED Facility Program (PAD Program) Participants
Appendix C: Pools Participating in Maryland AED Facility Program (PAD Program) and Map
Appendix D: COMAR 10.17.05 Definitions
2
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Background
Senate Bill 742 (Chapter 349, 2007) "Swimming Pools Automated External Defibrillators ­
Study" required the Maryland Institute for Emergency Medical Services Systems, in consultation
with interested stakeholders, to study whether automated external defibrillators (AEDs) should
be provided on-site at swimming pools in Maryland and to examine: 1) which swimming pools
should be required to provided AEDs; 2) whether the presence of individuals trained in the use of
automated external defibrillators should be required by swimming pools; and 3) the safety of
providing AEDs at a swimming pool. In addition, the statute required MIEMSS to make
recommendations on locations, other than swimming pools, where AEDs should be required.
This report contains information and results from analyses conducted on cardiac arrest data in
Maryland. MIEMSS conducted the analyses over the course of several months. Results were
reviewed and approved by the AED Task Force at its meeting on November 9, 2007 as well as .
by the State EMS Board at its November 13,2007 meeting. A listing ofthe members of the
AED Task Force, as well as other interested individuals who attended AED Task Force meetings
in 2007 is included at Appendix
A.
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Executive Summary
• Sudden cardiac arrest ("SCA") occurs when the heart develops an abnormal rhythm (usually
ventricular fibrillation or ventricular tachycardia) which results in a loss of an effective
heartbeat and death if not treated rapidly. Maryland has approximately 4,000 SCAs each
year.
• The abnormal heart rhythms that most commonly cause SCA are ventricular fibrillation and
ventricular tachycardia which frequently occur spontaneously and without warning. The
treatment for these abnormal heart rhythms is to shock the heart, a procedure called
"defibrillation. "
• Defibrillation is most effective if provided within 3 - 5 minutes of SCA and has limited or no
effectiveness after 10 minutes.
• Since the early 1990's, there have been increasing calls for placing AEDs in the community
for use by lay rescuers, a process referred to as "Public Access Defibrillation" ("PAD").
• The effectiveness of defibrillation in a given PAD program is directly related to the
percentage of arrests that are witnessed and how often and how quickly the rescuers are able
to obtain, correctly apply, and activate the AED. The cost-effectiveness of a given PAD
program is related to a number of factors including the likelihood of a cardiac arrest
occurring at the location and the likelihood that the victim will survive.
• A number of resources may be utilized to guide the State in making public policy decisions
regarding the response to out of hospital SCA, including National Guidelines, especially
from the American Heart Association, published peer reviewed scientific studies, legislative
trends in other states, and available data.
• Current American Heart Association guidelines recommend establishment of PAD Programs
at locations that are likely to have at least one SCA every 5 years and where the public
safety time to defibrillation is greater than 5 minutes. They also recommend PAD Programs
at health clubs with> 2500 members and places with a high likelihood of witnessed SCA
such as international airports, casinos, and sports facilities.
• A few states have passed legislation in the past several years mandating the establishment of
PAD programs at the following locations: schools
(1
0 states); health clubs, fitness centers,
health spas, health studios, gyms, weight control studios, and martial arts schools with> 500
members
(7
states); and places of public assembly (2 states).
• Maryland Cardiac Arrest Data indicate that the following high-risk locations should have the
capability to provide defibrillation within 3 to 5 minutes of SCA through a PAD program,
public safety, and/or the availability of AEDs or manual defibrillators for healthcare workers
at that location:
o BWI Marshall Airport (PAD program already in place)
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o
o
o
o
o
Skilled nursing facilities
Dialysis centers
Racecourses and racetracks
Enclosed malls
Hospitals and hospital premises
• Maryland Cardiac Arrest Data, national guidelines, legislative trends and the likelihood of a
higher percentage of witnessed SCAs indicate that the following intermediate risk locations
be should considered as potential locations for requiring the capability to provide
defibrillation within 3 to 5 minutes ofSCA through a PAD program and
lor
public safety;
o
o
o
o
o
o
o
o
o
o
o
Sports stadiums
Rehabilitation facilities
Ocean City beaches (PAD program already in place)
Amusement parks
Public parks
Colleges and universities
Golf courses
Health clubs and related facilities
Places oflarge public assembly
Casinos (if established in Maryland)
High rise residential facilities and housing complexes with greater than 250
individuals over the age of 50 present for 16 or more hours a day.
• Cost- effectiveness of PAD programs at intermediate risk locations is enhanced when the
locations are large/high exposure facilities (e.g. health clubs with more than 500 members
(AHA recommends 2500) or educational facilities with over 1000 students, faculty and staff
present).
• Requiring AEDs at every swimming pool is not currently supported based on an analysis of
national guidelines, legislative trends, and Maryland MCASS data. Voluntary placement of
AEDs at swimming pools, especially larger ones, as well as participation in PAD Programs
should be encouraged.
• Perceived barriers to participation in PAD Programs should be eliminated.
• MlEMSS should continue to trend data from MCASS, review national recommendations,
legislative trends, and published scientific studies and periodically report back to the
Legislature as new information becomes available. MIEMSS should also continue to work
toward obtaining hospital discharge information as the outcome measure for cardiac arrest;
however, this may require additional resources not currently available.
• Consideration should be given to greater investment in public safety AED programs fire,
EMS, and police - that are capable of arriving and defibrillating within 5 minutes of arrest.
At the present time, this is the only proven effective approach to addressing SCA in homes
which account for the vast majority of SCAs (about 80%).
5
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Introduction
Sudden cardiac arrest ("SCA") occurs when the heart develops an abnormal rhythm (usually
ventricular fibrillation or ventricular tachycardia) which results in a loss of an effective heartbeat
and death if not treated rapidly. These abnormal heart rhythms frequently occur spontaneous Iy
and without warning and may occur in any age group, although are more likely to occur in
individuals who are over 50 years of age.
There are an estimated 250,000 - 360,000 SCAs
in
the United States each year;
in
Maryland
there are approximately 4,000 SCAs each year. Most SCAs occur outside of a hospital; of those
SCAs occurring outside of a hospital, approximately 80% are in residential settings and 20% in
community settings.
The treatment for these abnormal heart rhythms is to shock the heart, a procedure called
"defibrillation." Defibrillation is most effective if provided within 3 - 5 minutes of SCA and has
limited or no effectiveness after 10 minutes. Cardiac arrests that occur secondary to other
events, e.g., trauma, electrocution, drug overdose, or drowning mayor may not require or benefit
from defibrillation.
In
the past, defibrillation was provided by healthcare providers (Le., physicians, nurses and
paramedics). With the development of computerized defibrillators called "automated external
defibrillators" ("AEDs"), however, individuals with far less medical training (such as fire, police,
and EMS first responders) may successfully defibrillate a victim of SCA. Fire and EMS
personnel responding to 911 calls, however, are frequently not able to reach a victim ofSCA
within 10 minutes of the arrest. Poor outcomes from out-of-hospital SCA are generally related to
the amount of time it takes these public safety personnel to reach the victim and administer
defibrillation. Survival from a witnessed out of hospital SCA varies significantly from
community to community, but is typically well below 10% (national published median 6.4%)
with some notable exceptions such as Seattle, Washington.
Public
Access
Defibrillation
Since the early 1990's, there have been increasing calls for placing AEDs in the community for
use by lay rescuers, a process collectively referred to as "Public Access Defibrillation" ("PAD").
PAD programs are based on the concept that AEDs are most effective when used within 3 to 5
minutes of SCA. Experience with PAD programs has also indicated that such programs are most
effective when the AEDs are used by persons who have received appropriate training and when
the AEDs are properly maintained. PAD programs have also been found to be effective at
certain high volume facilities, such as international airports, where the device is mounted on the
wall for access by bystanders who in many cases can successfully defibrillate the victim before
staff arrives. This has led to recommendations that public access AEDs be stored in plain sight
with sign age for access by bystanders at high risk locations.
The effectiveness of defibrillation in a PAD program is directly related to two factors: 1) the
percentage of arrests that are witnessed and 2) how often and how quickly the rescuers are able
to obtain, correctly apply, and activate the AED. A "witnessed" cardiac arrest is one where a
6
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bystander sees the victim collapse; the presence of such a bystander witness greatly increases the
chances that the bystander will intervene to help the victim and/or summon others to provide
immediate aid. Generally, an individual suffering an unwitnessed cardiac arrest has a poorer
chance of survival. The rapid response of the rescuers is another important factor: every minute
the victim is in cardiac arrest, chances of survival decrease by about 10%. The less time it takes
the rescuer to obtain the AED from its location, take it to the victim's side, and apply the AED,
the greater the changes of survival.
Studies have shown varying degrees of effectiveness of PAD programs. A recent study by the
National Institutes of Health / National Heart Lung
&
Blood Institute indicated that PAD
programs could potentially double the likelihood of successful resuscitation using trained lay
rescuers with medical oversight at selected high risk locations
l .
Also, PAD programs at
locations such as airports and casinos and with police officers have achieved remarkable results ­
49% -74% survival of victims ofa witnessed SCA2. Studies of AEDs in homes (where most
SCA occurs) have not been able to demonstrate effectiveness
3 •
Despite its apparent effectiveness, however, concerns have been expressed about the cost­
effectiveness of PAD programs. The cost-effectiveness of a given PAD program is related to a
number of factors including the likelihood of a cardiac arrest occurring at the location and the
likelihood that the victim will survive. Two factors generally increase the likelihood of a cardiac
arrest occurring at a given location - exposure (expressed as the person-years of individuals at a
particular location) and the characteristics of the individuals who are at the location (for instance,
individuals who are over 50).
Cost-effectiveness in health care interventions is believed to occur when the intervention results
in a cost equal to or less that $50,000 per year of life saved
4 •
With SCA, studies and
recommendations have indicated that this corresponds to one cardiac arrest per PAD location
Reed DB, Birnbaum A, Brown LH, O'Conner RE, et al. Location of Cardiac Arrests in the
Public Access Defibrillation Trial. Prehospital Emergency Care. 2006; 10(1 ):61-67.
I
2 Hazinski MF, Idris AH, Kerber RE, Epstein A, et al. Lay Rescuer Automated External
Defibrillator ("Public Access Defibrillation") Programs: Lessons Learned from an International
Multicenter Trial: Advisory Statement from the American Heart Association Emergency
Cardiovascular Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care;
and the Council on Clinical Cardiology. Circulation. 2005; 111:3336-3340.
3
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care, Part 5: Electrical Therapies: Automated External Defibrillators,
Defibrillation, Cardioversion, and Pacing. Circulation. 2005; 112(suppl IV):IV-19-IV-34.
Gold LS, Eisenberg M. Cost-effectiveness of automated external defibrillators in public places:
Pro. Curr Opin Cardiolology 2007; 22(1 ):5-10.
4
7
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every 5 - 10 years
5 6.
Further, placement of AEDs at high risk locations is generally thought to
be cost-effective because there is a greater likelihood that the AED will be used. However, these
high-risk locations represent only a small percentage of all out-of-hospital SCAs: only 1 2 % if
non-hospital health care facilities are excluded. Consequently, while cost-effective, placement of
AEDs at high risk locations is likely to have little impact at a population level. PAD programs
that place AEDs at low-risk locations are unlikely to be cost-effective since there is a smaller
likelihood that the AED will ever be used. And AED placement at low-risk locations may be
even less cost-effective than alternative approaches, such as prevention or improving public
safety response to SCA.
Maryland Public
Access
Defibrillation
Maryland's PAD program was implemented in 1999
7 •
The Program permits a business,
organization, association, etc. ("authorized facility"), that meets certain requirements, to set up a
program whereby someone suffering a cardiac arrest on the authorized facility's premises can
receive treatment with an automated external defibrillator (AED) on-site by appropriately trained
non-medical personnel before the arrival of emergency medical services personnel. An
authorized facility may be a single organization located at one place or a business that operates at
several locations (sites). In 2006, the Maryland General Assembly passed a law mandating
AEDs at all public high schools in Maryland
8 •
Participation by other types of facilities is
currently voluntarily; however, if a facility determines to have an AED on site, it must
participate in the Program.
Maryland's PAD Program sets forth specific requirements for authorized facilities, including
training of AED operators by an approved AED training program. Authorized facilities meeting
program requirements receive a certificate that is valid for three years if the facility remains
compliant with the program requirements. The program requirements may be found at COMAR
30.06.01-05.
Since the inception of the Maryland PAD Program, there have been 38 successful AED uses out
of212 reported incidents (18%) at PAD sites. Success is defined as the victim having a return of
pulse at EMS arrival or during EMS transport. Of the overall arrests, 125 were witnessed, and
34 of those witnessed arrests regained a pulse at the time of EMS arrival for a 27% save rate for
witnessed cardiac arrests.
5
Cram P, Vijan S, Fendrick AM. Cost-effectiveness of Automated External Defibrillator
Deployment in Selected Public Locations.
J.
General Internal Medicine. 2003; 18:745-754.
6
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care, Part 5: Electrical Therapies: Automated External Defibrillators,
Defibrillation, Cardioversion, and Pacing. Circulation. 2005; 112 (supp. IV):IV-19-IV-34.
SB 294, Ch. 167, 1999; Ed. Art. § 13-517, Ann. Code MD.
HB 1200, Ch. 203, 2006; Ed. Art. §7-425, Ann. Code MD.
7
8
8
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There are currently 874 facilities participating in the Program with just over 2,100 sites (see
Appendix B). Of these, 53 sites are community pools (see attached listing and map showing
community pool participants at Appendix
C).
Public Policy Development
A number of resources may be utilized to guide the State in making public policy decisions
regarding the response to out of hospital SCA. These include the following:
o
o
o
o
National Guidelines, especially from the American Heart Association;
Published peer-reviewed scientific studies;
Legislative trends and initiatives in other states; and
A vailab Ie statewide data specific to cardiac arrests.
National Guidelines and Pertinent Peer-Reviewed Research
Current American Heart Association guidelines recommend PAD programs be established at
locations that are likely to have at least one SCA every 5 years and where the public safety time
to defibrillation is greater than 5 minutes. They also recommend that PAD programs be
established at health clubs with> 2500 members and at places with a high likelihood of
witnessed SCA such as international airports, casinos, and sports facilities.
Research generally supports the current AHA recommendations for PAD programs that have an
emphasis on planning, training, practice of CPR and use of AEDs. Results support placement of
AEDs in those public locations with a high incidence or likelihood of SCA (e.g., airports, golf
clubs, health clubs, large industrial, sports, shopping malls).9
At least one published research study considers the AHA recommendation to be too
conservative, however. This study indicates that PAD programs may be cost effective ifthere is
a 12% annual likelihood of a sudden cardiac arrest at the location (at least once every 8-9
years)
10.
Further, in the National Institutes of Health / National Heart Lung
&
Blood Institute's
Public Access Defibrillation Trial, high risk locations were defined as having a history of at least
I cardiac arrest every 2 years or where there are 250 or more individuals 50 years or older for 16
hours or more a day. Results of the PAD trial indicate that the exposure-adjusted rate of SCA
9 Hazinski MF, Idris AH, Kerber RE, Epstein A, et at. Lay Rescuer Automated External
Defibrillator ("Public Access Defibrillation") Programs: Lessons Learned from an International
Multicenter Trial: Advisory Statement from the American Heart Association Emergency
Cardiovascular Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care;
and the Council on Clinical Cardiology. Circulation. 2005; 111 :3336-3340.
Cram P, Yijan S, Fendrick AM. Cost-effectiveness of Automated External Defibrillator
Deployment in Selected Public Locations.
J.
General Internal Medicine. 2003; 18:745-754.
10
9
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was highest in fitness centers and golf courses, even though the incidence per facility was low
and average respectively
II .
Legislative Trends
In 1997, states began enacting public access laws to encourage AED placement. All fifty states
have now have enacted certain AED laws. A review of recent legislative activity indicates that a
few states have passed legislation in the past several years requiring or supporting mandating the
establishment of PAD programs in certain locations.
• Schools - SCA is less likely to occur in children as compared to adults (0.18 per 100,000
person-years for students versus 4.51 per 100,000 person years for faculty and staff).
Despite this, the desire to ensure the safety and well-being of youth has led 10 states,
including Maryland, to require PAD programs at some schools. NY requires PAD at school
facilities with more that 1000 people on site.
• Health clubs, fitness centers, health spas, health studios, gyms, weight control studios, and
martial arts schools with> 500 members. Seven states have enacted such laws with some
exceptions to the requirements.
• Places of public assembly that typically host large numbers of people. Two states have
enacted requirements for AEDs at these types of locations.
: Schools
'Health
!Clubs
.... ......... ... .............
:Places of
[Public
i
.~.!~~~
.
I~.~.~y
..'''''........L................
~.~
....._....._..
~.
__
~~_.~
.....
~_.
__
~ _~ ~_.~_
.
~., ~_.w
....................
wJ
From: The National Conference of State Legislatures: State Laws on Heart Attacks, Cardiac
Arrest & Defibrillators Encouraging or requiring community access and use. See:
http://www.llcsl.org/programs/health/aed.htm
w ...
...
!Colorado (donations), Florida, Illinois, Maryland, Michigan, Nevada,
i
INew York, Ohio, Pennsylvania and Virginia require some schools to have
l
Iportable defibrillators; actual extent varies.
i
...T ................................................
w
......................................._....................................................................................................w................................................................................................. ....
j
iCalifornia, Illinois, Massachusetts (1/07), Michigan, New Jersey, New
YOrk and Rhode Island laws now require health clubs to have at least one
AED.
Definition example (Michigan):
"Health club" means an establishment
Ithat provides, as its primary purpose, services or facilities that are purported
Ito assist patrons in physical exercise, in weight control, or in figure
Idevelopment, including, but not limited to, a fitness center, studiO, salon, or
Iclub. A health club does not include a hotel or motel that provides physical
!fitness equipment or activities, an organization solely offering training or
Ifaci.l.i~.it:?!9~
...
~'!.i!:l9.iyi_d.
. l:!91?P9r:!'. ..
?~~
.
~t:i9~~Et:9~~~.i.?I!
.
~t:I!~t:r:...
.............................'
New York ('06); Arizona - any state building constructed or renovated at a
cost of at least $250,000 must be equipped with AEDs.
i
I
w .._ ..
....
.• _
................._ .._ _ _ _ _.......... _._ .....
..._ .....
Reed DB, Birnbaum A, Brown LH, O'Connor RE, et at. Location of Cardiac Arrests in the
Public Access Defibrillation Trial. Prehospital Emergency Care. 2006; 10(1 ):61-67.
11
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Maryland-Specific Data
MlEMSS initiated the Maryland Cardiac Arrest Surveillance System (MCASS) in 2001 to
identify and characterize out-of-hospital sudden cardiac arrests in Maryland. Out-of-hospital
sudden cardiac arrest is defined as any sudden stop in cardiac function that occurs out-of-hospital
and in which the state EMS system is accessed for resuscitative services. Out-of-hospital SCAs
occurring to individuals with valid EMS Do Not Resuscitate orders, those where the individual
was identified as dead on the arrival of EMS at the scene as well as those that do not contact the
EMS system (e.g., individuals under hospice care) are excluded from these surveillance numbers
(see Study Limitations). Data from these studies from the period January 1,2001 to December
31,2006 were reviewed for this report to identify the location of the cardiac arrest (e.g., school,
home, airport, etc.) and other factors.
There were 19,912 out-of-hospital cardiac arrests in Maryland between January 1,200 I and
December 31, 2006 that met the surveillance criteria and were reported to MIEMSS. Less than
half of these cardiac arrests were witnessed events. The majority of the witnessed events were
observed by a bystander. Cardiac arrests were highly likely to be witnessed when they occurred
at BWI airport, on public transportation, restaurants and bars, churches, enclosed malls,
courthouses, stadium, racecourses/racetracks, health clubs, dialysis centers, ambulances, and
physician/dentist offices.
Table I shows lists the annual rates per facility per year of out of hospital witnessed SCA, with
medical or unknown arrest etiology in Maryland by location type. The list further ranks
locations among three incident rate category types based upon a relative ranking per facility per
year: "high"
(l
or more SCA every
to
years), "intermediate"
(l
SCA every II - 100 years), or
"low" risk
(1
SCA every 101 years or more). In addition, the cumulative percents of total SCA
are provided to gauge the influence that category ranking has on the overall SCA popUlation.
Rates will vary within location types based upon exposure: those locations that have greater
numbers of individuals and demographic characteristics (e.g., bigger malls, amusement parks,
and buildings as well as health clubs with larger memberships will have greater exposure and
therefore a greater likelihood of SCA). The results of SCA by type of location are fairly
consistent with other studies ofSCA conducted in the U.S.; however, there have been relatively
few such studies.
Results indicate the following locations as being at a "high" risk for a witnessed SCA (at least I
witnessed SCA within a ten year period):
o
o
o
o
o
o
BWI Marshall Airport (PAD program already in place)
Skilled nursing facilities
Dialysis centers
Racecourses and racetracks
Enclosed malls
Hospitals and hospital premises
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Results indicate the following locations as being at an "intermediate" risk for a witnessed SCA
(at least 1 witnessed SCA every 11 to 100 years):
o
o
o
o
o
o
o
o
o
o
o
Sports stadiums
Rehabilitation facilities
Ocean City beaches (PAD program already in place)
Amusement parks
Public parks
Colleges and universities
Golf courses
Health clubs and related facilities
Places of large public assembly
Casinos should they be established in Maryland
High rise residential facilities and housing complexes with greater than 250
individuals over the age of 50 present for 16 or more hours a day.
Results indicate the following locations as being at a "low" risk for a witnessed SCA (at least 1
witnessed SCA per> 100 years):
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Other airport (small)
Adult day care
Hotel
I
Motel
Courthouse
Ambulance (Commercial service transporting patient while en route)
Industrial Place and Premises
Restaurant
I
Bar
Museum
School
I
educational facility (PK - 12)
Theater
I
Cinema
Other Public Beach
Physician
I
Dentist Office
Church
Home
Youth Camp
Community Pool
Child Day Care
Convention Center
The following locations are classified as "unknown," indicating that there was insufficient
information to complete a risk determination:
o
o
o
o
o
Senior Living Housing
Other Residential
Bus
I
Bus Station
Street
I
Highway
Public Transportation
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o
o
o
o
o
o
o
o
o
Other Transportation
Government Administration Building
Public Building
Retail Store (non-enclosed mall)
Senior Recreational Center
Other Building
Recreational Center
Urgent Care Facility
Other Medical Facility
Cardiac Arrest at Community Pools - Special Considerations
As previously mentioned, the effectiveness of resuscitation from SCA is usually calculated based
on the number of witnessed cardiac arrests of medic allcardiac or unknown etiology where an
abnormal cardiac rhythm is suspected to be the primary cause. A number of other known
conditions such as trauma and drownings may result in a cardiac arrest as a secondary condition.
The likelihood of a cardiac arrest requiring defibrillation is very high in primary cardiac arrests
because the primary problem is usually an abnormal heart beat that requires defibrillation. The
likelihood of a secondary cardiac arrests needing defibrillation is very variable.
The ranking of the locations listed above, including pools, was calculated based on the number
of witnessed cardiac arrests of medical/cardiac or unknown etiology where an abnormal cardiac
rhythm is suspected to be the primary cause. Over the six-year study period, four (4) witnessed
SCAs of medical/cardiac or unknown etiology and 13 drownings, for a total of 17 occurred at the
2,992 pools that were included in the study. One additional cardiac arrest was reported in
someone with a terminal illness.
If all cardiac arrests at pools rather than just the medical/cardiac and unknown etiology were
used, the resulting rate would be 1 SCA every 997.333 years. This rate is still very low relative
to other locations. See Table 1.
Defibrillation at Pools
Safety Issues
Regarding the safety of applying an AEO at a swimming pool, the American Heart Association
advises that use of an AEO at a pool presents a special situation and cautions that providing an
AEO shock to a victim lying in water or lying on a wet surface around a pool may cause bums or
shocks to the victim or rescuers. When a drowning is suspected, the AHA recommends first
removing the victim from the water, opening the airway, and attempting ventilations. If these
actions fail to resuscitate the victim, an AEO may be indicated and the following actions should
be undertaken when an AEO is available
12:
1. Remove the victim from contact with water.
2. Drag the victim gently by the arms or legs, or use a blanket drag.
American Heart Association. Heartsaver AEO for the Lay Rescuer and First Responder.
Page 3-5, 1997-99.
12
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3. Dry the victim's chest quickly before attaching the AED.
Conclusions and Recommendations
The capability to provide defibrillation within 3 to 5 minutes of SCA should be in place through
a PAD program, public safety, and/or the availability of AEDs or manual defibrillators for
healthcare workers at the following high risk locations:
o
o
o
o
o
o
BWI Marshall Airport (PAD program already in place)
Skilled nursing facilities
Dialysis centers
Racecourses and racetracks
Enclosed malls
Hospitals and hospital premises
The capability to provide defibrillation within 3 to 5 minutes of SCA should be in place through
a PAD program and / or public safety at the following intermediate risk locations based on
national guidelines, legislative trends, and higher percentages of witnessed SCAs:
o
o
o
o
o
o
o
o
o
o
o
Sports stadiums
Rehabilitation facilities
Ocean City beaches (PAD program already in place)
Amusement parks
Public parks
Colleges and universities
Golf courses
Health clubs and related facilities
Places of large public assembly
Casinos should they be established in Maryland
High rise residential facilities and housing complexes with greater than 250
individuals over the age of 50 present for 16 or more hours a day
Cost- effectiveness of PAD programs at intermediate risk locations is enhanced when the
locations are large/high exposure facilities (e.g. health clubs with more than 500 members (AHA
recommends 2500) or educational facilities with over 1000 students, faculty and staff present).
MIEMSS should continue to trend data from MCASS, review national recommendations,
legislative trends, and published scientific studies and modify public policy as new information
becomes available. Additionally, voluntary placement of AEDs at swimming pools and other
community locations, as well as participation in PAD Programs should be encouraged; perceived
barriers to participation in PAD Programs should be eliminated. The promising 27% "save rate"
for witnessed SCA at facilities currently participating in the Maryland PAD Program serves as a
public health incentive to encourage the growth of these programs; "save rate" means pulse at
EMS arrival or while being transported. Also, serious consideration should be given to greater
investment in public safety AED programs fire, EMS, and police - that are capable of arriving
and defibrillating within 5 minutes of arrest. At the present time, rapid response by public safety
14
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the only potentially effective approach to addressing SCA in homes which account for the vast
majority of SCAs.
Study Limitations
The MCASS database includes all out-of-hospital cardiac arrests in Maryland that are reported to
MIEMSS. All EMS personnel that provide care to an individual in cardiac arrest are requested
to submit copies of the following:
(I)
the Maryland Ambulance Infonnation System (MAIS)
Run Report or EMAIS equivalent; (2) the EMS Cardiac Arrest Supplemental Form; (3) a
narrative explaining the history of the cardiac arrest and subsequent treatment; and (4) the AED
or manual defibrillator summary report. The narrative is used to conduct quality assurance
checks on responses provided on the other forms. The MAIS master database, which comprises
ambulance run infonnation from all EMS incidents regardless ofthe nature of the incident, is
also queried for cardiac arrest cases that may have inadvertently not been submitted. These
incidents are followed up to obtain the necessary study information. Response times are
gathered from the MAIS report and validated from data provided by the local 9-\-1 systems. For
some jurisdictions, data are submitted by E-MAIS, the electronic equivalent of the MAIS Run
Report, EMS Cardiac Arrest Supplemental form and other reports.
All EMS jurisdictions in the state are expected to contribute information on all out-of-hospital
sudden cardiac arrest cases seen by EMS. Rigorous un-duplication measures are taken to ensure
that all documentation belonging to a single cardiac arrest incident is not split into multiple
incidents. Currently, there is no way to completely un-duplicate incidents reported in the MAIS
database. Therefore, infonnation provided from this state EMS database may contain
overestimates in the numbers. Also, the MCASS database does not contain all EMS
jurisdictional Information, including one of the largest jurisdictions in Maryland. The exact
amount of underreporting is unknown, but estimated to be in the range of 20%. It is doubtful,
however, that the underreporting will have a significant impact on the rank order of annual rates
by location. Finally, variability of reporting may exist across jurisdictions; data have not been
presented by jurisdiction in this report.
The statistics provided are generated from the Maryland EMS system. As such, they reflect only
those out-of-hospital cardiac arrests that notified and utilized the EMS system. The data do not
include out-of-hospital cardiac arrests that:
1. Do not contact the 9-1-1 system for care,
2. Contact the system but do not use the system due to the presence of a valid EMS
Do Not Resuscitate Order, or
3. No resuscitative efforts were provided by EMS and the patient was classified as
"Dead on Arrival" at the scene.
Also, this report provides a six-year aggregate ofthe data. Because cardiac arrests are a
relatively rare event, small numbers may greatly impact percentages and rates. This data
limitation is thought to directly affect the statistics associated with the locations in which cardiac
arrests occur, since there are a large number of subcategories of locations within the five main
categories.
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Rates for the place of occurrence charts are calculated using denominators from various sources.
Most of these sources are from state agencies or licensing bureaus and thought to be complete
and accurate. Other denominators such as shopping malls were obtained from Internet lists and
validated in statewide focus groups. Finally, other denominators such as the ones for churches,
hotels/motels and restaurants/bars were obtained from the yellow pages phone book. The lists
were checked for duplicates and misclassified listings; however, these denominators may provide
an overestimate of the true rate since the definition demands that the place of occurrence have a
listed phone number for the establishment. Averaging of the annual rates shown in the table may
not accurately capture the impact of the size of a given location on the likelihood of an SCA
event. Certain denominators, e.g., the number of streets and highways, could not be accurately
determined.
Definition of Community Pools
Information regarding the number of swimming pools included in the study was obtained from
the Department of Health & Mental Hygiene. Maryland State regulations define "Public Pools"
to include three (3) classifications:
I)
Recreational; 2) Semi-Public; and 3) Limited Public Use
Pools. See the language of COMAR 10.17.01 which is shown in Appendix D. This report used
all three types of public pools as the cardiac arrest denominator in determining the relative risk of
a witnessed SCA at a community pool. This was done for several reasons. First, there was no
definition of "pool" contained in the language of SB 742. Second, the DHMH information on
public pools came from local health departments which did not necessarily report the type of
"public pool." Third, the Maryland cardiac arrest data collection did not differentiate among
various types of community pools; rather, information was reported on "community pools"
generally. Thus, the decision to use the combined number of all three types of public pools was
determined to be reasonable.
If it is determined, however, that the combined pool number is inaccurate because it incorrectly
includes pools that would not appropriately qualify as "community pools," an alternative
methodology is to calculate the number of such community pools it would take to make pools
fall into the "high" risk category. Using this method, even if all 18 SCA victims (4 medical /
cardiac / unknown etiology, 13 drownings and I terminally
ill )
were deemed to have all been in
a shockable rhythm and thus eligible for use of an AED, the number of pools would have to
decrease from the current number of2,992 pools to no more than 30 in order for pools to be fall
in the "high risk" category. And, in order for pools to fall into the "intermediate risk" category,
the number of pools would have to be no more than 300. By any count, there are many more
than 300 community pools within the State of Maryland. Thus, the risk of SCA at community
pools cannot fall into the "high" or ."intermediate" categories under any reasonable methodology.
Despite the limitations of the study, the MCASS data reported in this study are well within the
range of data reported by other researchers.
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Table 1. Ranked Out-of-Hospital Witnessed Cardiac Arrests with Medical or Unknown Etiology
(All Ages), Calendar Years 2001-2006
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References
American Heart Association. Emergency Cardiac Care. Office of Public Advocacy.
Washington, D.C.
Aufderheide T, Hazinski MF, Nichol G, Smith Steffens S, et at. Community Lay Rescuer
Automated External Defibrillation Programs. Key State Legislative Components and
Implementation Strategies. A Summary of a Decade of Experience for Healthcare Providers,
Policymakers, Legislators, Employers, and Community Leaders From the American Heart
Association Emergency Cardiovascular Care Committee, Council on Clinical Cardiology, and
Office of State Advocacy. Circulation; February 28, 2006,113:1-11.
Becker L, Eisenberg M, Fahrenbruch C, Cobb
L.
Public Locations of Cardiac Arrest:
Implications for Public Access Defibrillation. Circulation 1998; 97:2106-2109.
Bhardwaj PK, Mohan M, Rai UC. Electrocardiographic changes in experimental drowning.
Indian J Physiol Pharmacol, 1982; 26( 1):85-90.
Coady SA, Sorlie PO, Cooper LS, Folsom AR, Rosamond WD, Conwill DE. Validation of Death
Certificate Diagnosis for Coronary Heart Disease: The Atherosclerosis Risk in Communities
(ARIC) Study. J Clinical Epidemiology. 2001; January; 54(1):40-50.
Cram P, Vijan S, Fendrick AM. Cost-effectiveness of Automated External Defibrillator
Deployment in Selected Public Locations. J. General Internal Medicine. 2003; 18:745-754.
Culley LL, Rea TO, Murray JA, Welles B, et al. Public Access Defibrillation in out-of-hospital
cardiac arrest: a community-based study. Circulation. 2004; 109(15): 1859-1863.
Engdahl J, Herliz J. Locations for out-of-hospital cardiac arrest in Goteborg 1994-2002 and
implications for public access defibrillation. Resuscitation. 2005; 64(2): 171-175.
Estes M. Prediction and Prevention of Sudden Cardiac Arrest: Lessons Learned in Schools.
Circulation. 2007; 116: 1341-1343.
Fedoruk JC, Currie WL, Gobet M. Locations of Cardiac Arrest: Affirmation for Community
Public Access Defibrillation (PAD) Program. Prehosp Disast Med 2002; 17(4):202-205.
Forrer CS, Swor RA, Jackson RE, Pascual RG, et al. Resuscitation. 2002; 52(1):23-29.
Gold LS, Eisenberg M. Cost-effectiveness of automated external defibrillators in public places:
Pro. Curr Opin Cardiolology 2007; 22(1 ):5-1
O.
Groenevelf PW, Kwong JL, Liu Y, Rodriquez AJ, et al. Cost-effectiveness of automated
external defibrillators on airlines. JAMA 2001; 286(12):1482-1489.
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Hazinski MF, Idris AH, Kerber RE, Epstein A, et al. Lay Rescuer Automated External
Defibrillator ("Public Access Defibrillation") Programs: Lessons Learned from an International
Multicenter Trial: Advisory Statement from the American Heart Association Emergency
Cardiovascular Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care;
and the Council on Clinical Cardiology. Circulation. 2005; 111:3336-3340.
Iribarren C, Crow RS, Hannan PJ, Jacobs DRJ, Luepker RV. Validation of Death Certificate
Diagnosis of Out-of-Hospital Sudden Cardiac Death. Am J Cardiology. 1998; 82: 50-53.
Johns Hopkins Medical Institutions (2007, November 7). Lives are Saved when Defibrillators
are Placed in Public Spaceds. Science Daily.
http://W\vw.sciencedaily.com/releases/2007/11/071105110632.htm
Nichol G, Hallstrom AP, Ornato 1P, Riegel B, et al. Potential Cost-effectiveness of Public
Access Defibrillation in the United States. Circulation. 1998; 97: 1315-1320.
Pell JP, Walker A, Cobbe SM. Cost effectives of automated external defibrillators in public
places: Con. Curr Opin Cardiology 2007; 22(1
):5
10.
Reed DB, Birnbaum A, Brown
LH,
O'Connor RE, et al. Location of Cardiac Arrests in the
Public Access Defibri lIation Trial. Prehospital Emergency Care. 2006; 10(1 ):61-67.
Rothmier 1D, Drezner JA, Harman KG. Automated external defibrillators at Washington State
high schools. Br 1. Sports Med. 2007; 41 (5):301-305.
Stehbens WE. Review of the Validity of National Coronary Heart Disease Mortality Rates.
Angiology. 1990; 41:85-94.
The Public Access Defibrillation Trial Investigators. Public-Access Defibrillation and Survival
after Out-of-Hospital Cardiac Arrest. NE1M 351 (7):637-646.
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AMENDMENT
To Bi1l26-12
BY COUNCILMEMBER LEVENTHAL
PURPOSE:
To title the law.
Beginning on page
5,
line 90, add Section
2
to read:
1
Sec. 2. This law may be citedas "Connor's Law."
f:\law\bills\1226 swimming pools - defibrillators\connors law amendmentdoc