In Place But Not Always Used: Automated External Defibrillators in Amateur Football

A sudden cardiac arrest (SCA) event is a condition in which the heart ceases its normal rhythm, disallowing normal circulation. SCA is one of the leading causes of death worldwide (21). Varying survival rates, ranging from 5% to 50%, have been found for patients experiencing an SCA (4). Additionally, neurological complications of varying degrees are often experienced after SCA survival (28). Bystander cardiopulmonary resuscitations (CPR) are only initiated in approximately 33% of all SCA events (17). Using an automated external defibrillator (AED) in the CPR process is associated with increased survival (15,19). SCA is the leading cause of sudden death among athletes (11,18). It is estimated that in the United States alone, one sports-related SCA occurs every 3 d (11,18). Since every day millions of people participate in sports activities, the incidence of an SCA can be high, and its impact is tragic (2,6,17). Automated external defibrillator availability in sport venues has become an important measure in adequate out-of-hospital SCA treatment (8–10,13,14,23). Close to all Dutch stadiums that host professional football games are equipped with AEDs (24) as well as approximately 80% of amateur sports clubs playing Gaelic football, football, or rugby in Ireland (7). However, to our knowledge, no research has been conducted on this matter among Dutch amateur football clubs. To fill this research gap, we conducted a systematic survey aimed at determining the availability, history, and knowledge of use of AEDs among amateur football clubs in the Netherlands. We designed an electronic quantitative survey with questions on baseline characteristics of participating amateur football clubs, availability of AEDs, history, and knowledge of use. An amateur football club was defined as a club where players are enrolled exclusively in a nonprofessional or unpaid manner. All Dutch amateur clubs affiliated with the Royal Netherlands Football Association (Dutch abbreviation: KNVB) were invited to participate in the survey via a mass-generated communication email sent by the KNVB. The survey was available for completion between May and June 2014. A total of 205 amateur football clubs participated in the survey. Most participating clubs (196, 95.6%) have 101 or more players. Most of these clubs have been in existence for more than 25 years (193, 93.6%) with only one club (0.5%) established during the past 5 yr. A total of 48 (23.4%) participating clubs have a formal medical team. Among these, 33 (68.7%) have a medical team consisting of one or two people, whereas 15 (31.2%) had three or more. Regarding AED ownership, 173 (84.4%) of the clubs have an AED, located mostly where the club teams play home games (72, 41.6%) or in the club canteen (74, 42.8%) (Table). Automated external defibrillators were either self-financed (70, 40.5%) or sponsored by another organization (63, 36.4%) (Table). The majority (167, 96.5%) of the clubs have AEDs available both for training activities and competitive games, and 138 (79.8%) of the clubs conduct regular maintenance on the AEDs (Table).Table: Characteristics associated with AED deployment.Guidelines regarding the use of AED are available in 123 (71.1%) of the participating clubs that own an AED (Table), most of which were provided by the supplier of the AED (61, 49.9%) or by local health care institutions (47, 38.2%). A total of 117 (67.6%) clubs have a person knowledgeable on the use of AED, both during trainings and competition games, compared with 28 (16.2%) that only have them during competition games, and 28 (16.2%) that do not have them at all. Furthermore, a follow-up training on the use of AED was provided by 120 (69.4 %) clubs. A spectator, bystander, or player experienced an SCA during a sports activity in the history of 72 (35.1%) participating clubs. An AED was used only 20 times (27.8% of all SCA events, 10% for all clubs owning an AED). Of these 72 SCA events, 28 patients survived (38.9% of all SCA events), 39 (54.2% of all SCA events) did not, and for the remaining 5 (6.9% of all SCA events) the outcome was unknown. Implications for Practice We observed that, in general, Dutch amateur football clubs are compliant with the deployment of AED in sport facilities. Most of the clubs that participated in our survey have had an AED for less than 5 yr, although more than 95% of them have been established for at least 25 yr. A majority of the clubs conduct regular maintenance of the AED and have guidelines available on how to use them. However, there is still a substantial proportion that do not observe this basic measure, since more than 15% of the clubs do not own an AED. Approximately 16% of clubs that do own an AED do not have a staff member trained on the use of the AED. Previous research has detected a high prevalence of incorrectly delivered CPR (both in and out of the hospital) (1,26). A clear association between CPR training, including the use of AED, and quality of the CPR techniques has been found (3,12,27). Consequently, suppliers of AEDs, local health care organizations, and other stakeholders should implement further efforts in providing continuous formal training regarding CPR techniques. A player or spectator experienced an SCA event in the history of approximately one third of participating football clubs. The high prevalence of SCA in sports venues stresses the importance of preparing treatment strategies, including AED availability and formal training on its use. In addition, it is worrisome that in more than 60% of the cases when an SCA event occurred, an AED was not used. As mentioned above, the use of an AED during an SCA event is of outmost importance for a successful outcome (13,20). Some research has been conducted on the cost-effectiveness of defibrillators as an emergency response. It has been found that AEDs are cost-effective when deployed in venues with a high density both of people at risk of suffering an SCA event and personnel trained on using AED (20). Both requirements are met by the football clubs included in our study. A limitation of our survey is the possibility of selection bias while sampling the target population. Invitation to participate was sent through a mass communication setting (i.e., newsletter), which precludes us from learning whether all potential participants read the invitation. Nevertheless, we adhered rigorously to the methodological requirements of this type of study (5,25), and the final number of participants in our study (n = 205) is similar or higher than that of equivalent studies (7,16,22). Another limitation is that most clubs that answered the survey had more than 100 players. Smaller clubs may be less compliant with AED availability on club premises and with other emergency response measures. However, smaller clubs are mostly informal and consist of unregistered teams of people. This falls beyond our reach since these collectives are not a part of the KNVB registry of amateur football clubs. Conclusions Most of the surveyed Dutch amateur football clubs have an AED available in their facilities. However, there is a need to continue campaigns advocating for compliance with this basic emergency response measure to achieve universal coverage. In addition, these campaigns must promote continuous training of personnel on the correct use and maintenance of the AED. Further research is required to assess the availability of AEDs in smaller clubs.