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The role of law enforcement agencies in out-of-hospital emergency care
Resuscitation (2007) 72, 386—393
CLINICAL PAPER
The role of law enforcement agencies in out-of-hospital emergency care夽 Seth C. Hawkins a,∗, Alan H. Shapiro b, Adrianne E. Sever c, Theodore R. Delbridge d, Vincent N. Mosesso e a
Department of Emergency Medicine, Grace Hospital, Blue Ridge Health Care, 2201 South Sterling Street, Morganton, NC 28655, United States b Department of Emergency Medicine, University of Pittsburgh Medical Center, Tri-Community South EMS, 4342 Lydia Street, Pittsburgh, PA 15207, United States c Department of Emergency Medicine, Emory University, 69 Jesse Hill Jr. Drive, Atlanta, GA 30303, United States d Department of Emergency Medicine, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, United States e Department of Emergency Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 911, Pittsburgh, PA 15213, United States Received 17 May 2006 ; received in revised form 14 July 2006; accepted 19 July 2006 KEYWORDS Automated external defibrillator; Emergency medical services; Emergency treatment; Cardiac arrest; Law enforcement; Police
Summary Background: A key component of out-of-hospital emergency care is the rapid response of trained providers with appropriate medical equipment. In some communities, law enforcement agents function as first responders to accomplish this goal. The purpose of this national survey was to assess the proportion of law enforcement agencies that provide medical care to determine the extent of care they provide, to identify how many use AEDs, and to assess the attitudes of agency leaders regarding their roles as medical first responders. Methods: Eight hundred agencies were selected at random from a national database of 43,000 agencies available through the National Public Safety Bureau (Stevens Pt, WI). These agencies were sent a 19-question survey either by US mail or telephone. Results: Four-hundred and fifty-four (57%) surveys were returned, and 420 (53%) were available for use after exclusion criteria were applied. Eighty percent of law enforcement agencies respond routinely to medical emergencies and 39% of these reported they deploy AEDs. Thirty-one percent of all law enforcement agencies are equipped with AEDs, a ten-fold increase from 2.6% reported in a previous national study in 1997. Funding issues were the most common reasons cited for not using AEDs.
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.07.021 ∗ Corresponding author. Tel.: +1 828 430 9942; fax: +1 828 580 6009. E-mail address: [email protected] (S.C. Hawkins).
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.07.021
The role of law enforcement agencies in out-of-hospital emergency care
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Approximately 75% of respondents agreed that law enforcement agencies should provide initial emergency medical care and indicated that officers in their agency would be willing to receive additional training to accomplish this. Conclusion: Based on this survey, law enforcement agents often serve as medical first responders. Nearly three quarters of responding agencies felt this role was appropriate. AEDs are now deployed much more frequently than indicated by a previous national study, but still less than one-third of law enforcement agencies carry AEDs as part of their standard response equipment. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction
Research design and methods
A key component of out-of-hospital emergency care is rapid access of patients to trained providers and medical equipment. Emergency medical services (EMS) systems were developed in most communities in the United States to address this need. Frequently EMS systems include ‘‘first responders’’, who use a limited amount of equipment and training to perform initial patient assessment and interventions, and assist more highly trained medical professionals upon their arrival. In some systems law enforcement agents are used as first responders. The only national survey of the role of law enforcement agencies of which we are aware was published in 1997.1 This first study found that 28% of law enforcement agencies consider some form of initial medical care of patients a main role for their officers in a medical emergency. In addition, it found that only 2.6% of law enforcement agencies were equipped with automatic external defibrillators (AEDs). It has been demonstrated subsequently that law enforcement officers, even in many disparate communities and throughout different countries, can be trained to operate AEDs effectively2—7 and relatively high patient survival could be obtained after equipping law enforcement officers with AEDs.8 Given these encouraging studies, we hypothesized that over the last half decade more law enforcement agencies have implemented use of AEDs. This study is intended to test that hypothesis by measuring law enforcement use of AEDs. In addition, although studies regarding AED use have been generally positive, law enforcement agencies themselves have been much more ambivalent regarding AED use, as well as law enforcement provision of medical care in general. The 1997 study revealed that 52% of agencies surveyed felt that EMS-related activities would interfere with their law enforcement duties.1 Our study also evaluates the current attitudes of these agencies regarding of out-of-hospital emergency care provided by law enforcement.
A comprehensive database of all law enforcement providers in the United States (43,000) is available through the National Public Safety Bureau (Stevens Pt, WI). We purchased 1600 unique agency listings randomly selected (via proprietary randomization software) by the Bureau. This is the smallest subset they make available. We eliminated every other listing, yielding 800 agencies. Assuming a simple random sampling design, we estimated that we would require 413 responses from 43,000 agencies to achieve a bound of ±5% on the point estimates for the primary survey questions (number of agencies providing medical care, and number of agencies equipped with AEDs).9 To allow for potential non-response, we attempted to obtain responses from these 800 agencies. This also allowed us to compare results (specifically return rate) with the prior 1997 survey more accurately, which also surveyed 800 agencies. A 19-item survey instrument based on the one used in the 1997 survey was developed. The 19 questions addressed demographic information, activities of law enforcement agencies in initial medical care, and concluded with a number of statements with which respondents expressed their level of agreement using a Likert scale (1 = strongly disagree, 5 = strongly agree). The survey was sent to the selected agencies through the US mail, which they returned via US mail to the investigators if they chose to participate. Returned surveys were excluded from the final study if the responding agency was not the primary law enforcement agency for their community or if the responding agency requested not to participate. Non-responders were re-mailed packets at 4 week intervals in the fall of 2003 for a total of three mailings. In the final stage of data acquisition we attempted to contact non-responders by phone from November of 2004 to April of 2005 using a standardized script to complete a survey or obtain participation refusal. Based on the time frame from the initial mailing it was decided to make no further efforts to obtain survey information from
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the persistent non-responders. As surveys were received, responses were separated from any identifying materials by a non-investigator staff person to ensure blinding. The data were then entered into a spreadsheet (Excel, Microsoft Corporation,
Table 1
Redmond, WA), converted to proportional terms, and tabulated. The results were divided into large (>24 officers) and small (24 officers or less) agencies to directly compare the results to the 1997 survey. A 2 or Fischer exact test was used
Characteristics of law enforcement agencies, and their communities and EMS system
Questions Number of LEA officers (median, [range]) Number of LEA vehicles in service at any one time (median, [range]) Community area (square miles) (median, [range]) Community population (median, [range])
Non-AED agencies (n = 288)
AED agencies (n = 132)
All agencies (n = 420)
12 [1—2996]
16 [1—1979]
13 [1—2996]
3 [1—925]
3 [1—420]
3 [1—925]
6 [1—608000] 6290 [300—1188580] n (%)
How would you characterize your community/jurisdiction?a Urban 67 (23.3) Suburban 74 (25.7) Rural 147 (51.0)
10 [1—6000]
7 [1—608000]
8250 [300—876000]
7000 [300—1188580]
n (%)
n (%)
4 (10.6) 71 (53.8) 47 (35.6)
81 (19.3) 145 (34.5) 194 (46.2)
Does your community utilize 911 as the primary telephone number to report emergencies? Yes 278 (96.5) 129 (97.7) Who provides ambulance service/emergency medical services (EMS) in your community? Fire department 116 (40.3) 58 (43.9) Municipal service 89 (30.9) 42 (31.8) Private service 97 (33.7) 44 (33.3) Police/Sheriff department 9 (3.1) 5 (3.8) Hospital service 11 (3.8) 0 (0.0) County service 23 (8.0) 5 (3.8) Volunteer service 14 (4.9) 9 (6.8)
407 (96.9)
b,c
174 (41.4) 131 (31.2) 141 (33.6) 14 (3.3) 11 (2.6) 28 (6.7) 23 (5.5)
Employment status of the EMS/ambulance service personnel in your community Volunteer 34 (11.8) 23 (17.4) Paid 166 (57.6) 48 (36.4) Both 81 (28.2) 59 (44.7) Unknown 7 (2.4) 2 (1.5)
57 (13.6) 214 (51.0) 140 (33.3) 9 (2.1)
Level of care that your community’s EMS/ambulance service offers Basic life support (BLS) 56 (19.4) Advanced life support (ALS) 38 (13.3) Both 174 (60.4) Unknown 20 (6.9)
30 (22.7) 33 (25.0) 64 (48.5) 5 (3.8)
86 (20.5) 71 (16.9) 238 (56.7) 25 (5.9)
of officers in your department? 34 (11.8) 1 (0.8) 33 (11.4) 15 (11.3) 146 (50.7) 54 (40.9) 69 (24.0) 57 (43.2) 4 (1.4) 5 (3.8) 0 0 2 (0.7) 0
35 (8.3) 48 (11.4) 200 (47.7) 126 (30.0) 9 (2.1) 0 2 (0.5)
What is the minimum level of medical training None CPR CPR and first aid First responder Emergency medical technician (EMT) Paramedic (EMT-P) Unknown
Do your officers routinely respond to medical emergencies? Yes 211 (73.3) a b c
127 (96.2)
Some law enforcement agencies reported multiple characteristics. Some law enforcement agencies reported multiple providers. Hospital, county, and volunteer were the only EMS entities reported as other.
338 (80.5)
The role of law enforcement agencies in out-of-hospital emergency care to analyze differences in the proportions of the answers to the Likert scale questions. This study was approved by the University of Pittsburgh Institutional Review Board (IRB number 0301076).
Results Four-hundred and fifty-four (57%) of the 800 surveys were returned. Ten respondents refused to participate. One survey was not available at the time of final data reconciliation. Thus 443 completed surveys were available. Twenty-three of the respondents indicated that they were not a primary law enforcement agency for a specific jurisdiction and their responses were not included. The final sample is comprised of 420 responses (53%) from primary law enforcement agencies. This sample size met the statistical goal of at least 413 responses. In terms of agency size, 291 agencies characterized themselves as small (24 officers or less) and 129 were large (>24 officers). Community and law enforcement agency characteristics are summarized in Table 1. The responding law enforcement agencies ranged in size from 1 to 2996 officers, have 1—925 vehicles, and serve a population ranging from 300 to 1,188,580. Ninety-six percent of communities used 911 as the primary telephone number to report emergencies. Overall, 31% (95% CI: 27—36%) of all law enforcement agencies surveyed are equipped with AEDs. Officers respond routinely to medical emergen-
Table 2 Questions
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cies in 80% (95% CI: 77—84%) of their respective communities. Table 2 presents the role of those agencies, which respond routinely to medical emergencies. Eighty-nine percent simultaneously dispatch EMS and law enforcement officers. Officers arrive prior to EMS 88% of the time. Nearly 50% of officers are required to have first aid training (which includes CPR), and 30% are required to have first responder training. However, only 39% of those agencies providing routine medical response carry AEDs as part of their standard responding equipment. Agencies reported a response time of less than 4 min in 59% of their emergency medical dispatches, while they have response time greater than 8 min in 28%. Sixty percent of officers provide initial medical care prior to EMS arrival, while 38% limit their roles to law enforcement. A field was provided for respondents to discuss why their officers did not use AEDs. One-hundred and thirty-seven respondents cited cost/money/lack of funds/budget constraints, 19 said other first responders had them, one was not permitted by their local government to purchase this technology, one department felt it was too overworked, and nine cited liability and training concerns. Table 3 demonstrates the proportion of respondents who agreed or strongly agreed with six statements about attitudes toward law enforcement agencies involvement in EMS. The representatives of those agencies that carried AEDs compared to those that did not more often ‘‘strongly agreed’’ or
Law enforcement agencies role in emergency carea Non-AED agencies (n = 211)
AED agencies (n = 127)
Is there simultaneous dispatch of EMS and law enforcement in your jurisdiction? Yes (%) 182 (86.2) 116 (91.3) Percentage of emergency medical calls in which LEA response time is <4 min 59.6% 4—8 min 24.1% >8 min 16.3% 67.9% In what percentage of the calls do your officers arrive at the scene prior to EMS/ambulance service? Role of officers on scene prior to EMS arrival Scene control/law enforcement 109 (51.6) (%) Provide initial medical care (%) 65 (30.8) Both (%) 32 (15.2) Not answered (%) 5 (2.4) a
Only includes LEA that routinely respond to medical emergencies.
All agencies (n = 338) 298 (88.2)
58.2% 31.1% 10.7%
59.1% 26.7% 14.2%
75.5%
70.7%
17 (13.4)
126 (37.3)
93 (73.2) 13 (10.2) 4 (3.2)
158 (46.7) 45 (13.3) 9 (2.7)
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Table 3 Attitudes of law enforcement officers towards a first responder role in emergency medical care (agree or strongly agree (%)) Statements
AED agencies (n = 132)
Non-AED agencies (n = 288)
All agencies (n = 420)
Pa
Law enforcement agencies should be involved in providing emergency medical services for life threatening situations in the community In general, officers in your agency would be willing to receive extra training to provide life-saving emergency care Adding emergency medical care functions to your agency would interfere with law enforcement responsibilities Adding emergency medical care functions would improve the public image of your agency If your department has an AED program, on the whole, it has been successful If your department does not have an AED program, you would support efforts to implement one
125 (95.0)
196 (68.0)
321 (76.4)
<0.001
118 (89.4)
196 (68.0)
314 (74.8)
0.0002
28 (21.2)
122 (42.4)
150 (35.7)
0.001
109 (82.6)
185 (64.2)
294 (70.0)
0.003
113 (85.6)
N/A
N/A
173 (60.1)
a
Compares AED vs. non-AED agencies.
‘‘agreed’’ that law enforcement agencies should be involved in providing emergency medical care for life saving situations (95.0% versus 68%, P < 0.001), that officers would be willing to receive extra training to provide life saving emergency care (89.4% versus 68%, P = 0.0002), and that adding emergency care functions would improve the public image of their agency (82.6% versus 64.2%, P = 0.003). Respondents of agencies that did not carry AEDs were more likely than those of agencies with AEDs to agree strongly/agree that adding emergency medical care functions to their agency would interfere with law enforcement responsibilities (42.4% versus 21.2%, P = 0.001). 85.6% of law enforcement agencies with an AED program believe it has been successful, while 60.1% of the departments that do not have an AED program would be willing to support efforts to implement one. Table 4 demonstrates the differences between large agencies and small agencies for the pertinent data.
Discussion The results of this nationwide survey reveal that many law enforcement agencies (91%) provide their officers with some level of medical training, and participate (60%) in emergency medical care (including 47% which provide exclusive medical care and 13% which provide dual law enforcement/medical care.) These data suggests that a large percentage of law enforcement agencies already have the necessary characteristics to enhance their community’s EMS system and are willing to increase their roles in pre-hospital emergency care. We are aware of one earlier national survey1 specifically addressing law enforcement agencies involvement in EMS. This prior study used a randomized nationwide sample via a mailing list of 800 law enforcement agencies from the American Police Hall of Fame and Museum. Our randomized sample of 800 police chiefs and sheriffs nationwide
The role of law enforcement agencies in out-of-hospital emergency care should allow for comparisons to be drawn directly between the two studies and to examine changes in the attitudes of law enforcement toward emergency medical care. Our findings indicate that approximately the same percentage of agencies reported routine response to medical emergencies as demonstrated previously in 1997 (80% versus 81%). In contrast, a significantly higher number of agencies now deploy AEDs than previously (31% versus 3%), and of those agencies who respond routinely to medical emergencies, 39% now use AEDs. Most commonly, those agencies not deploying AEDs implied they would be likely to deploy AEDs if adequate funding was available (137 respondents wrote in ‘‘funding’’, ‘‘cost’’, ‘‘lack of money’’, or ‘‘budget constraints’’ as the primary limitation to AED acquisition). Of note, a recent survey of the 200 most populous cities in the US demonstrated that 95.5% of first responders were equipped with AEDs.10 However, only two (1%) of the cities studied used law enforcement officers as medical first responders (the majority, 89%, used fire personnel), and these two cities used law enforcement agents equipped and trained to the ALS level. There has been a ten-fold increase in agencies equipped with AEDs, and yet over 2/3 of agencies still do not use this technology. Although efficacy of AEDs and patient mortality was not explicitly examined in this study, law enforcement arrives at the scene before EMS in 71% of systems studied. The benefit of early defibrillation for ventricular fibrillation cardiac arrest has been demonstrated in earlier studies, with a drop in the survival rate of 10% per minute of defibrillation delay.11 It is compelling that a majority of the agency administrators feel AEDs would be useful in their environment. Rather than logistical, attitudinal, or training obstacles, many agencies appear to not deploy AEDs because they have insufficient funds. In this sense, law enforcement access to AEDs should be considered in the larger public health discussion surrounding public access defibrillation (PAD). Police use of AEDs has been shown to be cost-effective.12 Some authors have suggested that PAD ‘‘has the potential to be one of the greatest advances in the treatment of sudden cardiac death since the development of CPR’’.13 Communities recognizing this may elect to fund law enforcement AEDs for early public access to this intervention in the same way as they fund law enforcement training in CPR, especially since in the majority of systems law enforcement is first to arrive at medical scenes. Such decisions need to be made with the individual characteristics of an agency in mind. For example, if EMS arrives before law enforcement
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(as is the case in 29% of systems studied); if other agencies (such as fire) are equipped with AEDs and arrive earlier than EMS; or if scene response times are similar or very low for EMS and other services, such as in many urban areas, communities may find no benefit from law enforcement AED deployment. Two reports from urban areas which equipped its fire first responders with AEDs showed no benefit in equipping police cars with AEDS.14,15 It would appear that small agencies might benefit most from exploring AED use. When compared to large agencies, they more often deployed officers to medical calls (83% versus 74%), these officers arrived more quickly at the scene (<4 min, 60% versus 56%; 4—8 min, 28% versus 25%), and more often arrived before an EMS unit (88% versus 85%). This concept is demonstrated by the successful police AED program in Rochester, MN.16 However, paradoxically, fewer small agencies are equipped with AEDs (31% of small agencies versus 33% of large agencies), and when comparing those agencies which respond routinely to medical emergencies, even fewer small agencies have access to AEDs (37% of small agencies versus 44% of large agencies). Although this study did not explore the reasons behind this disparity, we speculate a smaller size could correlate with reduced funding and smaller administrative staff, which could reduce pursuit of supplemental activities such as AED deployment. Public health and health care policy advocates should be aware that, in smaller agencies, the benefit for law enforcement AEDs appears higher but the prevalence of law enforcement AEDs is lower than in larger agencies. Based on the results of this study, they should consider exploring ways to expand AED use among smaller law enforcement agencies (and especially those that are already enthusiastic about initiating such a program). The caveat to this premise is the limited and somewhat negative experience in rural areas. The PARADE trial found that police arrived prior to EMS personnel in only 6.7% of arrests.17 Follow-up studies noted that only a third of officers felt comfortable using an AED and less than half believed AED use by law enforcement was needed.18 Another study found that police often reported non-use due to arrival of medical responders but dispatch records did not corroborate this.19 Compared to the earlier study, more respondents agreed with the statement that law enforcement agencies should provide initial emergency medical care (76% versus 62%), and with the statement that officers would be willing to receive additional medical training (74% versus 60%). More agencies also agreed that adding emergency med-
392 ical care functions would improve the public image of their agency (70% versus 52%) and less agencies believe that adding emergency medical care functions would interfere with law enforcement responsibilities (35% versus 53%). These findings are consistent with previous local surveys of systems with on-going police defibrillation programs.20,21 Perhaps most importantly, the majority (86%) of agencies that currently have AEDs deployed feel their use is successful. This high satisfaction rate, coupled with the fact that 10 times more agencies are using AEDs, suggests one of two conclusions: either agencies that previously felt AEDs would be onerous perceive the value of AEDs once they are obtained, or that more agencies that desired them in 1997 have been able to obtain them and find them as useful as expected.
Limitations and further study Despite aggressive data collection techniques we were only able to obtain a 57% survey return. We used similar techniques to those employed in the 1997 study, which reported a 77% return rate. Ten agencies we surveyed also refused to participate outright; although the earlier study reported 23% of surveys were not returned, they did not report any agency returning a study ‘‘refused’’ or refusing to participate by telephone. These are interesting results in themselves. One possible explanation is that there has been a change in the public safety agencies, which may have less staff, time or inclination to complete voluntary surveys or cooperate with medical research. Another possible explanation is that, coupled with the demonstrated increase in AED use, there has been an increased pressure on agencies to perform medical activities such as AED implementation. Agencies frustrated with this role may refuse to cooperate with surveys related to AED use or first responder activities. However, these are speculative reflections on an unexpected finding that was not our primary research goal. The reasons why law enforcement may be less inclined to cooperate with medical research, if our findings in this regard are valid, deserves further study in itself. As with all studies based on surveys, we are limited by the degree to which respondents interpreted the queries correctly. The validity of our results is also limited by the extent to which respondents used data versus estimation. The most common reason cited for not implementing AEDs was lack of funding. We did not
S.C. Hawkins et al. study the financial condition of the communities served by the law enforcement agencies, or the fiscal status of the law enforcement communities themselves. Future studies could explore whether there is a correlation between financial strength of agencies/communities and whether or not they use AEDs—–in other words, are AEDs predominately deployed in ‘‘rich’’ communities and lacking in ‘‘poor’’ communities? Finally, the survey did not clarify how many AEDs are employed, and whether all law enforcement officers are equipped with AEDs, or only a small portion, and where the AEDs are actually deployed (stations, cars, supervisor vehicles, etc.).
Conclusions Law enforcement agents often serve as medical first responders. Law enforcement agency respondents display more positive attitudes toward providing out-of-hospital emergency medical care and AED use than previously noted, especially those agencies that deploy AEDs. While law enforcement agencies now deploy AEDs much more frequently than previously reported, two out of three law enforcement agencies still do not. This may be responsible for many avoidable out-of-hospital deaths. Financial constraints are most often cited as the reason for not deploying AEDs. Law enforcement use of AEDs, especially by smaller agencies, should be considered when exploring the public health benefit of public access/EMS defibrillation programs.
Conflict of interest SCH, AHS, AES, TRD: none. VNM: research support from Cardiac Science, HeartSine, Medtronic, Philips, Welch-Allyn, and Zoll Medical Corporations, research grants through the University of Washington for the Public Access Defibrillation Trial and the Autopulse Assisted Prehospital International Resuscitation Trial, and funding from the National Center for Early Defibrillation, Pittsburgh, PA.
Acknowledgement The authors would like to thank Henry Wang, MD for statistical assistance and Evan Lebovitz for assistance with data collection.
The role of law enforcement agencies in out-of-hospital emergency care
References 1. Alonso-Serra, Delbridge TR, Auble TE, Mosesso VN, Davis EA. Law enforcement agencies and out-of-hospital emergency care. Ann Emerg Med 1997;29:497—503. 2. Mosesso VN, Baumann M, Davis E, Scott MA, Carlin RE, Plunkett W. Automated defibrillation by police first responders: device and operator performance. Prehospital Disaster Med 1995;10:S53. 3. Davis EA, Mosesso VN. Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest. Prehospital Emerg Care 1998;2:101—7. 4. Mosesso Jr VN, Baumann M, Davis EA, Auble TE, Paris P, Yealy DM. Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med 1998;32:200—7. 5. Santomauro M, Ottaviano L, Borrelli A, et al. Evaluation of BLS-D training in lay people. Ital Heart J Suppl 2004;5(7):527—33. 6. de Vries W, van Alem AP, de Vos R, van Oostrom J, Koster RW. Trained first-responders with an automated external defibrillator: how do they perform in real resuscitation attempts? Resuscitation 2005;64(2):157—61. 7. Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation 2002;106(9):1058—64. 8. White RD, Bunch TJ, Hankins DG. Evolution of a communitywide early defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 2005;65(3):279—83. 9. Scheaffer RL, Mendall W, Ott RL. Elementary survey sampling. 5th ed. Belmont, California: Duxbury Press; 1996. p. 99. 10. Williams DM. 2005 JEMS 200-city survey. J EMS 2006;31(2):59. 11. Marenco JP, Wang PJ, Link MS, et al. Improving survival from sudden cardiac arrest: the role for the automated external defibrillator. JAMA 2001;285(9):1193—200.
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12. Forrer CS, Swor RA, Jackson RE, Pascual RG, Compton S, McEachin C. Estimated cost effectiveness of a police automated external defibrillator program in a suburban community: 7 years experience. Resuscitation 2002;52(1):23—9. 13. Ross C, Schwab TM. Cardiopulmonary arrest. In: Wolfson AB, editor. Clinical practice of emergency medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 31. 14. Sayre MR, Evans J, White LJ, Brennan TD. Providing automated external defibrillators to urban police officers in addition to a fire department rapid defibrillation program is not effective. Resuscitation 2005;66(2):189—96. 15. van Alem AP, Vrenken RH, de Vos R, Tijssen JG, Koster RW. Use of automated external defibrillator by first responders in out of hospital cardiac arrest: prospective controlled trial. BMJ 2003;327(7427):1312. 16. White RD, Bunch TJ, Hankins DG. Evolution of a communitywide early defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 2005;65(3):279—83. 17. Groh WJ, Newman MM, Beal PE, Fineberg NS, Zipes DP. Limited response to cardiac arrest by police equipped with automated external defibrillators: lack of survival benefit in suburban and rural Indiana—–the police as responder automated defibrillation evaluation (PARADE). Acad Emerg Med 2001;8(4):324—30. 18. Groh WJ, Lowe MR, Overgaard AD, Neal JM, Fishburn WC, Zipes DP. Attitudes of law enforcement officers regarding automated external defibrillators. Acad Emerg Med 2002;9(7):751—3. 19. Lerner EB, Billittier IV AJ, Newman MM, Groh WJ. Automated external defibrillator (AED) utilization rates and reasons fire and police first responders did not apply AEDs. Prehospital Emerg Care 2002;6(4):378—82. 20. Papson K, Mosesso Jr VN. Ten years of police defibrillation: program characteristics and personnel attitudes. Prehospital Emerg Care 2005;9(2):186—90. 21. Prina LD, White RD, Atkinson EJ. Automated external defibrillators and first responders: a satisfaction survey. Resuscitation 2002;53(2):171—7.
CLINICAL PAPER
The role of law enforcement agencies in out-of-hospital emergency care夽 Seth C. Hawkins a,∗, Alan H. Shapiro b, Adrianne E. Sever c, Theodore R. Delbridge d, Vincent N. Mosesso e a
Department of Emergency Medicine, Grace Hospital, Blue Ridge Health Care, 2201 South Sterling Street, Morganton, NC 28655, United States b Department of Emergency Medicine, University of Pittsburgh Medical Center, Tri-Community South EMS, 4342 Lydia Street, Pittsburgh, PA 15207, United States c Department of Emergency Medicine, Emory University, 69 Jesse Hill Jr. Drive, Atlanta, GA 30303, United States d Department of Emergency Medicine, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, United States e Department of Emergency Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 911, Pittsburgh, PA 15213, United States Received 17 May 2006 ; received in revised form 14 July 2006; accepted 19 July 2006 KEYWORDS Automated external defibrillator; Emergency medical services; Emergency treatment; Cardiac arrest; Law enforcement; Police
Summary Background: A key component of out-of-hospital emergency care is the rapid response of trained providers with appropriate medical equipment. In some communities, law enforcement agents function as first responders to accomplish this goal. The purpose of this national survey was to assess the proportion of law enforcement agencies that provide medical care to determine the extent of care they provide, to identify how many use AEDs, and to assess the attitudes of agency leaders regarding their roles as medical first responders. Methods: Eight hundred agencies were selected at random from a national database of 43,000 agencies available through the National Public Safety Bureau (Stevens Pt, WI). These agencies were sent a 19-question survey either by US mail or telephone. Results: Four-hundred and fifty-four (57%) surveys were returned, and 420 (53%) were available for use after exclusion criteria were applied. Eighty percent of law enforcement agencies respond routinely to medical emergencies and 39% of these reported they deploy AEDs. Thirty-one percent of all law enforcement agencies are equipped with AEDs, a ten-fold increase from 2.6% reported in a previous national study in 1997. Funding issues were the most common reasons cited for not using AEDs.
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.07.021 ∗ Corresponding author. Tel.: +1 828 430 9942; fax: +1 828 580 6009. E-mail address: [email protected] (S.C. Hawkins).
0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.07.021
The role of law enforcement agencies in out-of-hospital emergency care
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Approximately 75% of respondents agreed that law enforcement agencies should provide initial emergency medical care and indicated that officers in their agency would be willing to receive additional training to accomplish this. Conclusion: Based on this survey, law enforcement agents often serve as medical first responders. Nearly three quarters of responding agencies felt this role was appropriate. AEDs are now deployed much more frequently than indicated by a previous national study, but still less than one-third of law enforcement agencies carry AEDs as part of their standard response equipment. © 2006 Elsevier Ireland Ltd. All rights reserved.
Introduction
Research design and methods
A key component of out-of-hospital emergency care is rapid access of patients to trained providers and medical equipment. Emergency medical services (EMS) systems were developed in most communities in the United States to address this need. Frequently EMS systems include ‘‘first responders’’, who use a limited amount of equipment and training to perform initial patient assessment and interventions, and assist more highly trained medical professionals upon their arrival. In some systems law enforcement agents are used as first responders. The only national survey of the role of law enforcement agencies of which we are aware was published in 1997.1 This first study found that 28% of law enforcement agencies consider some form of initial medical care of patients a main role for their officers in a medical emergency. In addition, it found that only 2.6% of law enforcement agencies were equipped with automatic external defibrillators (AEDs). It has been demonstrated subsequently that law enforcement officers, even in many disparate communities and throughout different countries, can be trained to operate AEDs effectively2—7 and relatively high patient survival could be obtained after equipping law enforcement officers with AEDs.8 Given these encouraging studies, we hypothesized that over the last half decade more law enforcement agencies have implemented use of AEDs. This study is intended to test that hypothesis by measuring law enforcement use of AEDs. In addition, although studies regarding AED use have been generally positive, law enforcement agencies themselves have been much more ambivalent regarding AED use, as well as law enforcement provision of medical care in general. The 1997 study revealed that 52% of agencies surveyed felt that EMS-related activities would interfere with their law enforcement duties.1 Our study also evaluates the current attitudes of these agencies regarding of out-of-hospital emergency care provided by law enforcement.
A comprehensive database of all law enforcement providers in the United States (43,000) is available through the National Public Safety Bureau (Stevens Pt, WI). We purchased 1600 unique agency listings randomly selected (via proprietary randomization software) by the Bureau. This is the smallest subset they make available. We eliminated every other listing, yielding 800 agencies. Assuming a simple random sampling design, we estimated that we would require 413 responses from 43,000 agencies to achieve a bound of ±5% on the point estimates for the primary survey questions (number of agencies providing medical care, and number of agencies equipped with AEDs).9 To allow for potential non-response, we attempted to obtain responses from these 800 agencies. This also allowed us to compare results (specifically return rate) with the prior 1997 survey more accurately, which also surveyed 800 agencies. A 19-item survey instrument based on the one used in the 1997 survey was developed. The 19 questions addressed demographic information, activities of law enforcement agencies in initial medical care, and concluded with a number of statements with which respondents expressed their level of agreement using a Likert scale (1 = strongly disagree, 5 = strongly agree). The survey was sent to the selected agencies through the US mail, which they returned via US mail to the investigators if they chose to participate. Returned surveys were excluded from the final study if the responding agency was not the primary law enforcement agency for their community or if the responding agency requested not to participate. Non-responders were re-mailed packets at 4 week intervals in the fall of 2003 for a total of three mailings. In the final stage of data acquisition we attempted to contact non-responders by phone from November of 2004 to April of 2005 using a standardized script to complete a survey or obtain participation refusal. Based on the time frame from the initial mailing it was decided to make no further efforts to obtain survey information from
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the persistent non-responders. As surveys were received, responses were separated from any identifying materials by a non-investigator staff person to ensure blinding. The data were then entered into a spreadsheet (Excel, Microsoft Corporation,
Table 1
Redmond, WA), converted to proportional terms, and tabulated. The results were divided into large (>24 officers) and small (24 officers or less) agencies to directly compare the results to the 1997 survey. A 2 or Fischer exact test was used
Characteristics of law enforcement agencies, and their communities and EMS system
Questions Number of LEA officers (median, [range]) Number of LEA vehicles in service at any one time (median, [range]) Community area (square miles) (median, [range]) Community population (median, [range])
Non-AED agencies (n = 288)
AED agencies (n = 132)
All agencies (n = 420)
12 [1—2996]
16 [1—1979]
13 [1—2996]
3 [1—925]
3 [1—420]
3 [1—925]
6 [1—608000] 6290 [300—1188580] n (%)
How would you characterize your community/jurisdiction?a Urban 67 (23.3) Suburban 74 (25.7) Rural 147 (51.0)
10 [1—6000]
7 [1—608000]
8250 [300—876000]
7000 [300—1188580]
n (%)
n (%)
4 (10.6) 71 (53.8) 47 (35.6)
81 (19.3) 145 (34.5) 194 (46.2)
Does your community utilize 911 as the primary telephone number to report emergencies? Yes 278 (96.5) 129 (97.7) Who provides ambulance service/emergency medical services (EMS) in your community? Fire department 116 (40.3) 58 (43.9) Municipal service 89 (30.9) 42 (31.8) Private service 97 (33.7) 44 (33.3) Police/Sheriff department 9 (3.1) 5 (3.8) Hospital service 11 (3.8) 0 (0.0) County service 23 (8.0) 5 (3.8) Volunteer service 14 (4.9) 9 (6.8)
407 (96.9)
b,c
174 (41.4) 131 (31.2) 141 (33.6) 14 (3.3) 11 (2.6) 28 (6.7) 23 (5.5)
Employment status of the EMS/ambulance service personnel in your community Volunteer 34 (11.8) 23 (17.4) Paid 166 (57.6) 48 (36.4) Both 81 (28.2) 59 (44.7) Unknown 7 (2.4) 2 (1.5)
57 (13.6) 214 (51.0) 140 (33.3) 9 (2.1)
Level of care that your community’s EMS/ambulance service offers Basic life support (BLS) 56 (19.4) Advanced life support (ALS) 38 (13.3) Both 174 (60.4) Unknown 20 (6.9)
30 (22.7) 33 (25.0) 64 (48.5) 5 (3.8)
86 (20.5) 71 (16.9) 238 (56.7) 25 (5.9)
of officers in your department? 34 (11.8) 1 (0.8) 33 (11.4) 15 (11.3) 146 (50.7) 54 (40.9) 69 (24.0) 57 (43.2) 4 (1.4) 5 (3.8) 0 0 2 (0.7) 0
35 (8.3) 48 (11.4) 200 (47.7) 126 (30.0) 9 (2.1) 0 2 (0.5)
What is the minimum level of medical training None CPR CPR and first aid First responder Emergency medical technician (EMT) Paramedic (EMT-P) Unknown
Do your officers routinely respond to medical emergencies? Yes 211 (73.3) a b c
127 (96.2)
Some law enforcement agencies reported multiple characteristics. Some law enforcement agencies reported multiple providers. Hospital, county, and volunteer were the only EMS entities reported as other.
338 (80.5)
The role of law enforcement agencies in out-of-hospital emergency care to analyze differences in the proportions of the answers to the Likert scale questions. This study was approved by the University of Pittsburgh Institutional Review Board (IRB number 0301076).
Results Four-hundred and fifty-four (57%) of the 800 surveys were returned. Ten respondents refused to participate. One survey was not available at the time of final data reconciliation. Thus 443 completed surveys were available. Twenty-three of the respondents indicated that they were not a primary law enforcement agency for a specific jurisdiction and their responses were not included. The final sample is comprised of 420 responses (53%) from primary law enforcement agencies. This sample size met the statistical goal of at least 413 responses. In terms of agency size, 291 agencies characterized themselves as small (24 officers or less) and 129 were large (>24 officers). Community and law enforcement agency characteristics are summarized in Table 1. The responding law enforcement agencies ranged in size from 1 to 2996 officers, have 1—925 vehicles, and serve a population ranging from 300 to 1,188,580. Ninety-six percent of communities used 911 as the primary telephone number to report emergencies. Overall, 31% (95% CI: 27—36%) of all law enforcement agencies surveyed are equipped with AEDs. Officers respond routinely to medical emergen-
Table 2 Questions
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cies in 80% (95% CI: 77—84%) of their respective communities. Table 2 presents the role of those agencies, which respond routinely to medical emergencies. Eighty-nine percent simultaneously dispatch EMS and law enforcement officers. Officers arrive prior to EMS 88% of the time. Nearly 50% of officers are required to have first aid training (which includes CPR), and 30% are required to have first responder training. However, only 39% of those agencies providing routine medical response carry AEDs as part of their standard responding equipment. Agencies reported a response time of less than 4 min in 59% of their emergency medical dispatches, while they have response time greater than 8 min in 28%. Sixty percent of officers provide initial medical care prior to EMS arrival, while 38% limit their roles to law enforcement. A field was provided for respondents to discuss why their officers did not use AEDs. One-hundred and thirty-seven respondents cited cost/money/lack of funds/budget constraints, 19 said other first responders had them, one was not permitted by their local government to purchase this technology, one department felt it was too overworked, and nine cited liability and training concerns. Table 3 demonstrates the proportion of respondents who agreed or strongly agreed with six statements about attitudes toward law enforcement agencies involvement in EMS. The representatives of those agencies that carried AEDs compared to those that did not more often ‘‘strongly agreed’’ or
Law enforcement agencies role in emergency carea Non-AED agencies (n = 211)
AED agencies (n = 127)
Is there simultaneous dispatch of EMS and law enforcement in your jurisdiction? Yes (%) 182 (86.2) 116 (91.3) Percentage of emergency medical calls in which LEA response time is <4 min 59.6% 4—8 min 24.1% >8 min 16.3% 67.9% In what percentage of the calls do your officers arrive at the scene prior to EMS/ambulance service? Role of officers on scene prior to EMS arrival Scene control/law enforcement 109 (51.6) (%) Provide initial medical care (%) 65 (30.8) Both (%) 32 (15.2) Not answered (%) 5 (2.4) a
Only includes LEA that routinely respond to medical emergencies.
All agencies (n = 338) 298 (88.2)
58.2% 31.1% 10.7%
59.1% 26.7% 14.2%
75.5%
70.7%
17 (13.4)
126 (37.3)
93 (73.2) 13 (10.2) 4 (3.2)
158 (46.7) 45 (13.3) 9 (2.7)
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Table 3 Attitudes of law enforcement officers towards a first responder role in emergency medical care (agree or strongly agree (%)) Statements
AED agencies (n = 132)
Non-AED agencies (n = 288)
All agencies (n = 420)
Pa
Law enforcement agencies should be involved in providing emergency medical services for life threatening situations in the community In general, officers in your agency would be willing to receive extra training to provide life-saving emergency care Adding emergency medical care functions to your agency would interfere with law enforcement responsibilities Adding emergency medical care functions would improve the public image of your agency If your department has an AED program, on the whole, it has been successful If your department does not have an AED program, you would support efforts to implement one
125 (95.0)
196 (68.0)
321 (76.4)
<0.001
118 (89.4)
196 (68.0)
314 (74.8)
0.0002
28 (21.2)
122 (42.4)
150 (35.7)
0.001
109 (82.6)
185 (64.2)
294 (70.0)
0.003
113 (85.6)
N/A
N/A
173 (60.1)
a
Compares AED vs. non-AED agencies.
‘‘agreed’’ that law enforcement agencies should be involved in providing emergency medical care for life saving situations (95.0% versus 68%, P < 0.001), that officers would be willing to receive extra training to provide life saving emergency care (89.4% versus 68%, P = 0.0002), and that adding emergency care functions would improve the public image of their agency (82.6% versus 64.2%, P = 0.003). Respondents of agencies that did not carry AEDs were more likely than those of agencies with AEDs to agree strongly/agree that adding emergency medical care functions to their agency would interfere with law enforcement responsibilities (42.4% versus 21.2%, P = 0.001). 85.6% of law enforcement agencies with an AED program believe it has been successful, while 60.1% of the departments that do not have an AED program would be willing to support efforts to implement one. Table 4 demonstrates the differences between large agencies and small agencies for the pertinent data.
Discussion The results of this nationwide survey reveal that many law enforcement agencies (91%) provide their officers with some level of medical training, and participate (60%) in emergency medical care (including 47% which provide exclusive medical care and 13% which provide dual law enforcement/medical care.) These data suggests that a large percentage of law enforcement agencies already have the necessary characteristics to enhance their community’s EMS system and are willing to increase their roles in pre-hospital emergency care. We are aware of one earlier national survey1 specifically addressing law enforcement agencies involvement in EMS. This prior study used a randomized nationwide sample via a mailing list of 800 law enforcement agencies from the American Police Hall of Fame and Museum. Our randomized sample of 800 police chiefs and sheriffs nationwide
The role of law enforcement agencies in out-of-hospital emergency care should allow for comparisons to be drawn directly between the two studies and to examine changes in the attitudes of law enforcement toward emergency medical care. Our findings indicate that approximately the same percentage of agencies reported routine response to medical emergencies as demonstrated previously in 1997 (80% versus 81%). In contrast, a significantly higher number of agencies now deploy AEDs than previously (31% versus 3%), and of those agencies who respond routinely to medical emergencies, 39% now use AEDs. Most commonly, those agencies not deploying AEDs implied they would be likely to deploy AEDs if adequate funding was available (137 respondents wrote in ‘‘funding’’, ‘‘cost’’, ‘‘lack of money’’, or ‘‘budget constraints’’ as the primary limitation to AED acquisition). Of note, a recent survey of the 200 most populous cities in the US demonstrated that 95.5% of first responders were equipped with AEDs.10 However, only two (1%) of the cities studied used law enforcement officers as medical first responders (the majority, 89%, used fire personnel), and these two cities used law enforcement agents equipped and trained to the ALS level. There has been a ten-fold increase in agencies equipped with AEDs, and yet over 2/3 of agencies still do not use this technology. Although efficacy of AEDs and patient mortality was not explicitly examined in this study, law enforcement arrives at the scene before EMS in 71% of systems studied. The benefit of early defibrillation for ventricular fibrillation cardiac arrest has been demonstrated in earlier studies, with a drop in the survival rate of 10% per minute of defibrillation delay.11 It is compelling that a majority of the agency administrators feel AEDs would be useful in their environment. Rather than logistical, attitudinal, or training obstacles, many agencies appear to not deploy AEDs because they have insufficient funds. In this sense, law enforcement access to AEDs should be considered in the larger public health discussion surrounding public access defibrillation (PAD). Police use of AEDs has been shown to be cost-effective.12 Some authors have suggested that PAD ‘‘has the potential to be one of the greatest advances in the treatment of sudden cardiac death since the development of CPR’’.13 Communities recognizing this may elect to fund law enforcement AEDs for early public access to this intervention in the same way as they fund law enforcement training in CPR, especially since in the majority of systems law enforcement is first to arrive at medical scenes. Such decisions need to be made with the individual characteristics of an agency in mind. For example, if EMS arrives before law enforcement
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(as is the case in 29% of systems studied); if other agencies (such as fire) are equipped with AEDs and arrive earlier than EMS; or if scene response times are similar or very low for EMS and other services, such as in many urban areas, communities may find no benefit from law enforcement AED deployment. Two reports from urban areas which equipped its fire first responders with AEDs showed no benefit in equipping police cars with AEDS.14,15 It would appear that small agencies might benefit most from exploring AED use. When compared to large agencies, they more often deployed officers to medical calls (83% versus 74%), these officers arrived more quickly at the scene (<4 min, 60% versus 56%; 4—8 min, 28% versus 25%), and more often arrived before an EMS unit (88% versus 85%). This concept is demonstrated by the successful police AED program in Rochester, MN.16 However, paradoxically, fewer small agencies are equipped with AEDs (31% of small agencies versus 33% of large agencies), and when comparing those agencies which respond routinely to medical emergencies, even fewer small agencies have access to AEDs (37% of small agencies versus 44% of large agencies). Although this study did not explore the reasons behind this disparity, we speculate a smaller size could correlate with reduced funding and smaller administrative staff, which could reduce pursuit of supplemental activities such as AED deployment. Public health and health care policy advocates should be aware that, in smaller agencies, the benefit for law enforcement AEDs appears higher but the prevalence of law enforcement AEDs is lower than in larger agencies. Based on the results of this study, they should consider exploring ways to expand AED use among smaller law enforcement agencies (and especially those that are already enthusiastic about initiating such a program). The caveat to this premise is the limited and somewhat negative experience in rural areas. The PARADE trial found that police arrived prior to EMS personnel in only 6.7% of arrests.17 Follow-up studies noted that only a third of officers felt comfortable using an AED and less than half believed AED use by law enforcement was needed.18 Another study found that police often reported non-use due to arrival of medical responders but dispatch records did not corroborate this.19 Compared to the earlier study, more respondents agreed with the statement that law enforcement agencies should provide initial emergency medical care (76% versus 62%), and with the statement that officers would be willing to receive additional medical training (74% versus 60%). More agencies also agreed that adding emergency med-
392 ical care functions would improve the public image of their agency (70% versus 52%) and less agencies believe that adding emergency medical care functions would interfere with law enforcement responsibilities (35% versus 53%). These findings are consistent with previous local surveys of systems with on-going police defibrillation programs.20,21 Perhaps most importantly, the majority (86%) of agencies that currently have AEDs deployed feel their use is successful. This high satisfaction rate, coupled with the fact that 10 times more agencies are using AEDs, suggests one of two conclusions: either agencies that previously felt AEDs would be onerous perceive the value of AEDs once they are obtained, or that more agencies that desired them in 1997 have been able to obtain them and find them as useful as expected.
Limitations and further study Despite aggressive data collection techniques we were only able to obtain a 57% survey return. We used similar techniques to those employed in the 1997 study, which reported a 77% return rate. Ten agencies we surveyed also refused to participate outright; although the earlier study reported 23% of surveys were not returned, they did not report any agency returning a study ‘‘refused’’ or refusing to participate by telephone. These are interesting results in themselves. One possible explanation is that there has been a change in the public safety agencies, which may have less staff, time or inclination to complete voluntary surveys or cooperate with medical research. Another possible explanation is that, coupled with the demonstrated increase in AED use, there has been an increased pressure on agencies to perform medical activities such as AED implementation. Agencies frustrated with this role may refuse to cooperate with surveys related to AED use or first responder activities. However, these are speculative reflections on an unexpected finding that was not our primary research goal. The reasons why law enforcement may be less inclined to cooperate with medical research, if our findings in this regard are valid, deserves further study in itself. As with all studies based on surveys, we are limited by the degree to which respondents interpreted the queries correctly. The validity of our results is also limited by the extent to which respondents used data versus estimation. The most common reason cited for not implementing AEDs was lack of funding. We did not
S.C. Hawkins et al. study the financial condition of the communities served by the law enforcement agencies, or the fiscal status of the law enforcement communities themselves. Future studies could explore whether there is a correlation between financial strength of agencies/communities and whether or not they use AEDs—–in other words, are AEDs predominately deployed in ‘‘rich’’ communities and lacking in ‘‘poor’’ communities? Finally, the survey did not clarify how many AEDs are employed, and whether all law enforcement officers are equipped with AEDs, or only a small portion, and where the AEDs are actually deployed (stations, cars, supervisor vehicles, etc.).
Conclusions Law enforcement agents often serve as medical first responders. Law enforcement agency respondents display more positive attitudes toward providing out-of-hospital emergency medical care and AED use than previously noted, especially those agencies that deploy AEDs. While law enforcement agencies now deploy AEDs much more frequently than previously reported, two out of three law enforcement agencies still do not. This may be responsible for many avoidable out-of-hospital deaths. Financial constraints are most often cited as the reason for not deploying AEDs. Law enforcement use of AEDs, especially by smaller agencies, should be considered when exploring the public health benefit of public access/EMS defibrillation programs.
Conflict of interest SCH, AHS, AES, TRD: none. VNM: research support from Cardiac Science, HeartSine, Medtronic, Philips, Welch-Allyn, and Zoll Medical Corporations, research grants through the University of Washington for the Public Access Defibrillation Trial and the Autopulse Assisted Prehospital International Resuscitation Trial, and funding from the National Center for Early Defibrillation, Pittsburgh, PA.
Acknowledgement The authors would like to thank Henry Wang, MD for statistical assistance and Evan Lebovitz for assistance with data collection.
The role of law enforcement agencies in out-of-hospital emergency care
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12. Forrer CS, Swor RA, Jackson RE, Pascual RG, Compton S, McEachin C. Estimated cost effectiveness of a police automated external defibrillator program in a suburban community: 7 years experience. Resuscitation 2002;52(1):23—9. 13. Ross C, Schwab TM. Cardiopulmonary arrest. In: Wolfson AB, editor. Clinical practice of emergency medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 31. 14. Sayre MR, Evans J, White LJ, Brennan TD. Providing automated external defibrillators to urban police officers in addition to a fire department rapid defibrillation program is not effective. Resuscitation 2005;66(2):189—96. 15. van Alem AP, Vrenken RH, de Vos R, Tijssen JG, Koster RW. Use of automated external defibrillator by first responders in out of hospital cardiac arrest: prospective controlled trial. BMJ 2003;327(7427):1312. 16. White RD, Bunch TJ, Hankins DG. Evolution of a communitywide early defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 2005;65(3):279—83. 17. Groh WJ, Newman MM, Beal PE, Fineberg NS, Zipes DP. Limited response to cardiac arrest by police equipped with automated external defibrillators: lack of survival benefit in suburban and rural Indiana—–the police as responder automated defibrillation evaluation (PARADE). Acad Emerg Med 2001;8(4):324—30. 18. Groh WJ, Lowe MR, Overgaard AD, Neal JM, Fishburn WC, Zipes DP. Attitudes of law enforcement officers regarding automated external defibrillators. Acad Emerg Med 2002;9(7):751—3. 19. Lerner EB, Billittier IV AJ, Newman MM, Groh WJ. Automated external defibrillator (AED) utilization rates and reasons fire and police first responders did not apply AEDs. Prehospital Emerg Care 2002;6(4):378—82. 20. Papson K, Mosesso Jr VN. Ten years of police defibrillation: program characteristics and personnel attitudes. Prehospital Emerg Care 2005;9(2):186—90. 21. Prina LD, White RD, Atkinson EJ. Automated external defibrillators and first responders: a satisfaction survey. Resuscitation 2002;53(2):171—7.