This means that bystander and community-based CPR plays a significant role in return of spontaneous circulation (ROSC) after cardiac arrest. However, audits of out of hospital cardiac arrest still show the frequency of BCPR remains poor, with less than one-third of cardiac arrest victims benefiting from BCPR before emergency services arrive (Eisenburger and Safar, 1999). The importance of BCPR is evidenced in one UK study by Dowie et al. (2003). Their work with the London Ambulance Service showed that BCPR increased the chance of survival by 10% over a monitored period of time. However, this study demonstrated a high percentage of BCPR (44%) in progress when the ambulance arrived.

Early Defibrillation

In the past few decades, the advent of automated external defibrillators (AEDs) in public places has meant that early access to defibrillation has become much more common. Advances in manufacturing and technology mean these simple and accurate AEDs can be used safely in workplaces, public places and even in the home (Jorgensen et al., 2003). Evidence is undisputed regarding the significance of early defibrillation. When the International Liaison Committee on Resuscitation (ILCOR) published its guidelines for CPR and emergency cardiac care in 2000, it stated:

With reported survival rates of up to 49%, PAD (public access defibrillation) has the potential to be the single greatest advance in the treatment of prehospital sudden cardiac death since the invention of CPR.

Yet appropriate placement of AEDs is still contested. Handley et al. (2005) reflect the most common opinion that defibrillators should be sited in places where large numbers of the public gather or pass though (railway stations, airports, shopping centres etc) and where cardiac arrests occur once every two years or more. Similarly, remote areas where ambulance response times are likely to be extended also influence where AEDs and community based programmes should be sited. This is supported by most national defibrillation programme planners and ILCOR (2000) suggest that PAD programmes prove to be cost effective when measured against years of added life. However, Handley et al (2005) remind us that up to 80% of cardiac arrests occur in residential or private settings. This then needs to be addressed through emergency dispatch systems to enable rapid responses with a defibrillator to residential settings as well as public places. Community first responders must therefore arrive on scene within five minutes – before emergency medical services – to be a truly effective resource, although their target response time is eight minutes.

The European Resuscitation Council and the European Society of Cardiology recognised the significance of community-based defibrillation and in 2004 produced policy statements making recommendations surrounding the use of AEDs in Europe. These included guidance for:

• legislation
  
• training and updating lay and co-responders
  
• access to and via emergency service call systems
  
• audit of AED use
  
• needs analyses
  
• cost benefits to public health.

First Responders

The UK has seen rapid development of first and community first responder schemes in the last decade. Community first responders are:

…volunteers who respond to emergency calls within their local community. They are generally lay people who have received basic medical training from their ambulance service. They respond, when available, to immediately life-threatening calls, usually in a rural area or one that is difficult for ambulances to reach within the current time target of eight minutes. They are not a substitute for professional paramedics and technicians, but they augment the ambulance service’s response.

(Healthcare Commission, 2007)

First responders come from a variety of backgrounds – from co-responders in other emergency services (police, fire, coastguard), staff in public places providing a localised emergency response (e.g. shopping centres, railway stations and airports), first aid organisation partners or volunteers from military backgrounds, to the general public keen to support emergency response systems in their local communities. They are not employees of ambulance services, but when called out by the ambulance services act as agents for them as part of the emergency response (Healthcare Commission 2007). Many nurses and healthcare practitioners are taking up this voluntary role.

First responder groups are set up in areas of identified need – now mostly influenced and defined by local ambulance service audit data in order to be sure of a co-ordinated response backed up by technicians/paramedics. The Healthcare Commission (2007) indicated that ambulance services see benefits in community first responder schemes, which have already had a positive impact on response times.

Colquhoun et al. (2008) show that although community first responders attending home and community-based cardiac arrests is a relatively new concept in the UK, and cost benefits have not yet been evaluated, they are worthy of support and continued funding to prove their value in time. They showed that these responders are achieving comparable results to the ambulance services. The key to ongoing work is that any public access and community response defibrillation programme must be aligned to the ambulance services based on data about incidence of sudden cardiac arrest and response times (Priori et al., 2004).

Summary

Coronary heart disease continues to exert a huge burden on patients, families, health services and society. Chest pain and sudden death form major parts of that burden. Implementation of the NSF has been associated with many improvements in care, including faster access to care and uptake of evidence-based treatments in both primary and secondary care settings. Preventative strategies have continued to have a high national profile. As the NHS undergoes significant reorganisation and care becomes more community focused, cardiac nurses will need to continue to develop their skills and expertise towards working in these challenging times, in order to contribute to reducing the cardiac risk.

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