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Automated defibrillators are likely to be placed in areas with the least need for them. New research found they are more often placed in wealthier areas and where people work; they are less common in deprived areas.  The researchers call for a strategy to ensure these devices are placed where there is greatest need.

A defibrillator delivers a shock which can restart someone’s heart after it stops beating (cardiac arrest). If this is done within a few minutes of the heart stopping, it improves the chances of survival. Automated defibrillators are for everyone to use and require no training.

Previous work has shown that most cardiac arrests occur in more deprived areas. Yet there is no coordinated national strategy to ensure that automated defibrillators are placed in these areas. Individuals, groups, and companies can apply for funding, and put the defibrillators near where they live or work without advice (though ambulance services may be involved).

Following this study, the researchers call for a strategy to ensure devices are put where they can help most people. They should be in prominent places which are easily accessed at all times. Guidance on applying for funding for automated defibrillators needs to be more widely publicised.

What’s the issue?

Emergency medical staff attempt to restart heart and breathing (resuscitation) for around 39,000 people in the UK each year. On average, it takes staff about 7 minutes to get to the person with cardiac arrest, but in rural areas, it can take longer.

Defibrillation (an electric shock to the heart) can restart a heart after cardiac arrest but needs to be delivered as soon as possible. Delay is costly: each extra minute reduces the chances of survival to hospital discharge by 10%. Few people in the UK (5%) who have a cardiac arrest receive defibrillation before paramedics arrive.

Previous work has shown that most (80%) out-of-hospital cardiac arrests occur in residential areas. People from minority ethnic groups and those from more deprived areas are most at risk.

Ambulance services have a database of automated defibrillators that have been registered. It means they can direct people to them in an emergency. These defibrillators are designed for anyone to use - no special training is needed.

International guidelines recognise the importance of automated defibrillators; European guidelines recommend they are placed where there has been an out-of-hospital cardiac arrest in the past 5 years. Still, many public areas in the UK do not have these devices, and they are not necessarily placed where out-of-hospital cardiac arrests have occurred. Initiatives to have them in the most appropriate places have not led to lasting change.

Community groups in the UK can apply for funding for an automated defibrillator. There is no government policy on providing automated defibrillators for communities. Supermarkets and offices often have an automated defibrillator, but it needs to be easily reached and never locked; it needs to be available outside of opening hours.

This study explored access to defibrillators in different areas.

What’s new?

The study compared the characteristics of areas with registered automated defibrillators in England, to those without. There were more than 32,000 devices in the study. The Office of National Statistics provided data on the level of deprivation (such as income, employment, and education), the number of residential areas and the proportion of different ethnic groups within the population.

The researchers found inequalities in access to automated defibrillators.

Automated defibrillators were more common in:

  • the most affluent areas (45% had at least 1 device) compared with the most deprived areas (27% had at least 1 device)
  • urban areas (64% had at least 1 device) compared with rural areas (36% had at least 1 device)
  • areas in which most people are White
  • places with fewer residents and more places of work
  • the South than the North
  • areas with a higher proportion of people aged 65 years and older.

The spread of devices registered to each ambulance service was inconsistent. For example:

  • 20% of areas in the North East had a device
  • 64% of areas in the East Midlands had a device.

Why is this important?

People living in areas with the highest need for automated defibrillators have the least access to them. The results reinforce the need for an evidence-based strategy on where to put automated defibrillators.

Areas which include more places of work see fewer cardiac arrests than residential areas. This was not reflected in the placement of automated defibrillators. The availability of these devices should be prioritised in areas of more deprivation.

The study calls for automated defibrillators to be placed in prominent locations everywhere, such as outside of supermarkets or schools. Devices have to be accessible at all times. The public needs to know where they are and that they can be used with no training.

What’s next?

An earlier initiative to place automated defibrillators in busy public places was successful. The National Defibrillator Programme showed that easy access to devices doubled survival. However, this did not lead to a national strategy. Now, both the UK Cardiovascular Disease Outcome Strategy and the NHS Long Term Plan recognise the need to improve access to and registration of automated defibrillators.

This research team is developing guidelines about where automated defibrillators should be located, based on where cardiac arrests occur.

Devices need to be registered so that people can be directed to them in an emergency call, the researchers say. This study included 32,000 devices but there may be others that are not registered. The British Heart Foundation (BHF) has developed ‘The Circuit’, a central point where people can register a defibrillator. The BHF will make information available to every ambulance service so that it can be accessed during an emergency call.

In addition, funding for the defibrillators should be more widely publicised among different communities to help reduce inequalities.

You may be interested to read

The paper this NIHR Alert is based on: Brown T, and others. Are there disparities in the location of automated external defibrillators in England? Resuscitation 2022;170:28-35

A paper describing the characteristics of areas with a high incidence of out-of-hospital cardiac arrest: Brown T, and others. Characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates in England. European Heart Journal Quality of Care 2019;5:51-62

A paper showing that Restart a Heart (RSAH) training is more likely to be carried out in areas of least need: Hawkes C A, and others. Characteristics of Restart a Heart 2019 event locations in the UK. Resuscitation Plus 2021;6:100132

Funding: The research was part of a larger study funded by the NIHR Health Services and Delivery Research Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

This is part of a larger body of work aimed at improving access to automated defibrillators. Information about how to purchase an automated defibrillator needs to be much more widely shared. When a device is available, it needs to be registered with the ambulance service to make sure it gets used.

There needs to be more public awareness of where automated defibrillators are. Their locations could be standardised, for instance outside every school, or in old telephone boxes.

There should be easier access to first aid training and automated defibrillator use everywhere, but especially in deprived areas. Initiatives to raise public awareness of basic first aid are important. Restart a Heart Day is a good example. It is run in collaboration with the Resuscitation Council UK, British Heart Foundation, British Red Cross, St John Ambulance, NHS Ambulance Service and Saving Lives for Scotland.

Terry Brown, Assistant Professor, University of Warwick 

British Heart Foundation 

This research clearly highlights how defibrillators are less likely to be placed in deprived areas and yet the risk of cardiac arrest occurring in these areas is usually high.

With over 30,000 out of hospital cardiac arrests each year in the UK, and a survival rate of less than one in 10, there is an urgent need for a coordinated, evidence-based defibrillator placement strategy. In the ultimate medical emergency, access to a defibrillator could be the difference between life and death.

The BHF wants to see defibrillators made more accessible and available across the UK. Through The Circuit: the national defibrillator network, we have made progress in ensuring that more defibrillators than ever are visible to ambulance services in an emergency. However, more needs to be done to provide equitable access to defibrillators so that more lives can be saved.

Judy O’Sullivan, Director of Innovation In Health Programmes at the British Heart Foundation 

Paramedic 

As an ambulance clinician, I recognise the time limitations of responding to cardiac arrest cases. It does not matter how many ambulances are on duty, there will always be some delay between collapse and arrival of emergency medical services. Having public members start cardiopulmonary resuscitation (CPR) early and applying an automated external defibrillator (AED) does result in better patient outcomes. From personal experience, I have seen the impact early defibrillation has on patient outcome and it cannot be overstated.

This paper highlights the disparity in AED availability throughout the UK. Early defibrillation should be readily available to everyone, and the distribution of AEDs should be based on that need. Data from this paper shows that devices are disproportionately placed where they are least needed. Thus, future AED programmes should use this information as part of their planning.

Policy and funding changes may help agencies take this message seriously. The provision of AEDs must be proportionate to the community need. It is up to local councils to recognise their unique situations, report their need, and educate the public on where AEDs are and how to use them.

Enrico Dippenaar, Paramedic, Chelmsford 

Member of the public 

I should hope that this paper would help to address health inequalities and potentially improve overall survival rates after a cardiac arrest. It highlights the issues around knowing the whereabouts of automatic defibrillators for the public, especially people with a history of cardiac arrest. Perhaps 999 call handlers could have access to location data via an app/GPS?

More public information campaigns are needed (for instance posters locally advertising where automatic defibrillators are found, as well as a link to download a locator app).

The research should help target limited resources to the areas of greatest need which would benefit most patients. It raises awareness of the importance of early intervention in relation to survival rates. Local fundraisers, community leaders, councillors and decision makers should all be made aware of this research in their pursuit of funding for these devices.

Casey Nolan, Public Contributor, Bath 

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