In-Hospital Defibrillation

This letter was intended to criticize the treatment of the problem of delayed in-hospital defibrillation in the current Textbook of ACLS. A revised edition of the Textbook came out in July 1997 with the relevant passage unchanged; a previous personal communication from the principal author seemed to be saying that this was either a stylistic oversight or a non-issue because it was not explicitly stated that early in-hospital defibrillation should not be attempted with conventional defibrillators. I continue to think that the passage is significant and that my criticism remains valid. The recent AHA medical/scientific statement "In-hospital Resuscitation" is an improvement in that it explicitly endorses use of conventional defibrillators as well as AEDs.

Stewart JA. Delayed in-hospital defibrillation. Annals of Emergency Medicine 1996; 27(1): 5-6.

Delayed in-hospital defibrillation

To the Editor:

Rapid defibrillation is widely recognized as the most important determinant of survival after cardiac arrest, and numerous early defibrillation programs across the country have led to significant increases in out-of-hospital survival rates. The American Heart Association (AHA) has strongly supported these prehospital programs for some years; however, the AHA has only recently begun to address the serious and widespread problem of delayed defibrillation within hospitals. This recent attention is certainly welcome, but AHA writings on the subject show a disturbing tendency to prematurely limit the scope of discussion about possible solutions--most prominently in the current (1994) edition of the Textbook of Advanced Cardiac Life Support  [1]. The problem of delayed in-hospital defibrillation warrants an open discussion of a variety of possible remedies. The AHA should issue a clear position statement to that effect, thereby modifying the narrow perspective evident in the Textbook of ACLS.

In its current edition, the Textbook for the first time clearly recognizes the problem of delayed in-hospital defibrillation--and then immediately proposes a single solution. In fact, the heading of the relevant section, "In-Hospital Use of AEDs: Delays in Defibrillation," announces the remedy even before naming the problem. The text recommends that hospitals purchase and use AEDs (automated external defibrillators) to deal with delayed defibrillation; the authors fail to address possible alternatives using existing equipment.

By presenting AEDs as the only solution, the authors imply that a deliberate, rational assessment of the problem has determined that speed of defibrillation cannot be improved with currently available equipment. However, a review of the literature strongly suggests that delayed in-hospital defibrillation is not due to heretofore inadequate technology but rather  to the failure of the health care community to recognize the problem. Moreover, the literature indicates that rapid in-hospital defibrillation is indeed feasible with the manual defibrillators that are standard equipment in most hospital units. [2-5 ]

The 1994 Textbook of ACLS also appears to endorse a policy change by the AHA that would require hospital staff to undergo AED training by making it a standard part of basic life support training, which is already required of licensed caregivers. Such a change would make additional training for manual defibrillation harder to justify, in effect promoting the purchase of AEDs by hospitals.

The AHA should encourage objective evaluation of innovative approaches to treatment-particularly those that involve new technologies, before they gain widespread acceptance.

In the emotionally charged atmosphere of medical care, the momentum of a new technology too often puts the burden of proof on those who question the evidence for it, rather than on those who propose it. The result is that the technology quickly becomes the accepted thing to do [and] further attempts to test it are subject to the charge of being unethical.... [6]

AED manufacturers will keep the AED option in the forefront of discussions about delayed in-hospital defibrillation; as a public service organization, the AHA should actively encourage consideration of a broad range of alternatives. There may be ways to achieve the goal of rapid in-hospital defibrillation less expensively--and much sooner--than by making progress contingent on the successful marketing of AEDs to hospitals. A clear statement from the AHA would do much to counter the narrow focus on AEDs found in the Textbook of ACLS and at the same time encourage action to remedy this serious and long-neglected problem.

1. American Heart Association: Textbook of Advanced Cardiac Life Support. Dallas, AHA, 1994.

2. Bradley K, Sokolow AE, Wright KJ: A comparison of an innovative four-hour EMT-D course with a "standard" ten-hour course. Ann Emerg Med 1988; 17: 613-619.

3. Stewart JA: Defibrillation training for general unit nurses. J Emerg Nurs 1992; 18: 519-524.

4. MacKintosh AF, Crabb ME, Brennan H, Williams J, Chamberlain DA: Hospital resuscitation from ventricular fibrillation in Brighton. BMJ 1979; 1: 511-513.

5. Stewart AJ, Lowe MD: Knowledge and attitudes of nurses on medical wards to defibrillation. J R Coll Physicians Lond 1994; 28(5): 399-401.

6. Russell, LB: Technology in Hospitals: Medical Advances and Their Diffusion. Washington, The Brookings Institution, 1979.

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