Public Access Defibrillation (PAD) State Law Fact Sheet

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Introduction
Background
Data Collection and Methods
Summary of State Laws
Implications and Trends
References

Introduction

This State Law Fact Sheet describes the landscape of state laws that address the attributes of a comprehensive public access defibrillation (PAD) program recommended by the American Heart Association (AHA) and other national organizations.

The recommended attributes of a comprehensive PAD program include:

Targeted automated external defibrillator (AED) site placement
Training anticipated responders
Emergency medical services (EMS) coordination
Emergency response plans
Routine maintenance and testing of AEDs
Continuous quality improvement
Limited civil liability or qualified immunity¹

The fact sheet describes 13 types of PAD program interventions codified in state law that support comprehensive PAD programs.² Interested stakeholders can use this information to help scale up PAD program interventions through an evidence-informed state law. Seven of these interventions have a best or promising evidence base, as described in the 2017 What Evidence Supports State Laws to Enhance Public Access Defibrillation? A Policy Evidence Assessment Report. The other six interventions, not explicitly addressed in the report, include related legal provisions states used to regulate their PAD programs.

This fact sheet summarizes state law in effect on June 30, 2017, addresses the 13 PAD interventions, and describes recent temporal trends in state PAD law, such as the widespread adoption of AED placement and the requirement that students learn to use an AED before they graduate.

For a summary of the PAD program interventions addressed in state law, see PAD Interventions by Evidence Rating below.

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Background

More than 356,000 out-of-hospital cardiac arrests (OHCAs) are reported annually in the United States.³ An estimated 70% to 90% of people experiencing OHCA die before reaching the hospital.^{4, 5}

Cardiopulmonary resuscitation (CPR) and use of an automated external defibrillator (AED) within minutes of OHCA can dramatically raise survival rates but are not commonly used or available.^6–9 A 2018 study reported AED use at 10.8% in public settings before emergency medical services (EMS) arrive.¹⁰

To increase OHCA survival rates, public access defibrillation (PAD) programs can use interventions that ensure AEDs are immediately accessible when needed.¹¹

Expansive evidence supports the efficacy of structured PAD programs that:

Disseminate AEDs for rapid access by lay bystanders
Train potential AED users
Link to EMS
Conduct quality improvement to improve system response^7,12–1⁷

The placement of AEDs at public locations where cardiac arrest is likely to occur (schools,^{4, 18–24} casinos, federal buildings, airports, fitness centers, churches, and workplaces^{4, 2}) has been found to:

Increase OHCA survival^{4, 22, 25–29}
Increase rates of return of spontaneous circulation^{29, 30}
Improve neurological outcomes for patients^{4, 30, 31}

In 2006, the AHA recommended states adopt legislative approaches to support community lay rescuer PAD programs.^{32, 33} As of 2010, all 50 states and the District of Columbia had enacted one or more laws to:

Increase the availability and use of AEDs
Limit civil liability for lay bystander AED use
Require businesses, schools, and others to implement PAD programs¹

OHCA survival rates varied widely among communities across the country.⁴ A 2015 Institute of Medicine (IOM) report recommended addressing legal barriers to bystander CPR and defibrillation and provided policy strategies for improving patient outcomes for cardiac arrest.⁴ This report noted that OHCA response and survival were affected by the quality of community health care systems, education, and local stakeholder collaboration.

The report also recommended the following changes to improve OHCA outcomes:

Creating a national registry to track cardiac arrest events and outcomes
Requiring AED placement and use training in schools
Improving EMS cardiac arrest recognition and treatment coordination
Conducting PAD program quality improvement initiatives
Increasing related research

Data Collection and Methods

We examined the extent that state law included 13 types of PAD interventions. Of these 13 interventions, three had “best” and four had “promising” evidence base ratings, according to the 2017 PAD Policy Evidence Assessment Report.¹ Six interventions were not specifically assessed in the evidence report.

Using the policy surveillance research method developed by the Center for Public Health Law Research (CPHLR) at Temple University, a research team consisting of CPHLR policy analysts and CDC policy researchers systematically collected, reviewed, and redundantly coded the body of PAD law (statutes and regulations) in the 50 states and the District of Columbia (hereafter collectively referred to as “states”) in effect from January 1, 2015, through June 30, 2017, under the supervision of a CDC senior public health analyst.

The team used the Westlaw search engine (Thomson Reuters, Eagan, Minnesota) to identify all relevant PAD laws, using the search terms “automated external defibrillator,” “automatic external defibrillator,” “public access defibrillator,” or “defibrillat!,” “defibrilat!,” “AED,” or “cardiac arrest.” The body of law for each state was coded according to whether each policy intervention was addressed in law (by being required, authorized, encouraged, or prohibited).

For quality assurance, researchers redundantly coded the body of PAD law for 20 states. All divergences were discussed by the researchers and the supervisor until a resolution was reached. Coding for the remaining states was reanalyzed to ensure that coding resolutions were applied uniformly across states.

Below is an outline of the PAD program interventions addressed in existing state law, organized by their evidence rating.

For a more detailed assessment, see the Policy Evidence Assessment Report: What Evidence Supports State Laws to Enhance Public Access Defibrillation? ¹

Targeted Site Placement

Placement of AEDs at any location where OHCA may be more likely to occur, such as fitness facilities, workplaces, airports, hallways, etc., based on specific criteria^a
Evidence rating: Best
AED placement specifically within schools
Evidence rating: N/A (not assessed)

Training Anticipated Responders

AED training of anticipated lay responders who are likely to be present in a specific type of setting (e.g., employees of a health club) or as part of their official duties (e.g., school officials)
Evidence rating: Best
AED training requirement for school graduation (high school, middle school, or other grade levels)
Evidence rating: N/A (not assessed)

Emergency Medical Services Coordination

AED location registry or EMS notification of placement/removal of AED; activation of EMS when an AED is used (excluding testing)^bEvidence rating: Best

Emergency Response Plans

AED program facilitator (or other) develops emergency response plan for responding to a suspect OHCA occurrenceEvidence rating: Promising
AED response plan is written/formalized
Evidence rating: N/A
AED response plan is practiced
Evidence rating: N/A

Routine Maintenance and Testing

AED maintenance and testing, including civil immunity provided if AED is maintained
Evidence rating: Promising

Ongoing Quality Improvement/Assurance Monitoring

Develop and implement quality improvement and assurance plans to evaluate and monitor the effectiveness of the PAD program
Evidence rating: Promising
AED clinical use reporting
Evidence rating: N/A
Medical professional oversight of PAD programs
Evidence rating: N/A

Immunity/Limited Liability

Civil immunity (or limited liability) for lay rescuers and others involved with AED use, purchase, acquisition, placement, programs, and/or training on use^c
Evidence rating: Promising

For the state law assessment, targeted site placement was analyzed as two interventions: 1) specified location (such as fitness centers, gambling venues) and 2) specific placement on site (such as hallways, near a telephone).
EMS coordination was analyzed as two interventions in the state law assessment: 1) EMS notification of placement/removal of AED; and 2) EMS activation when an AED is used during medical emergencies.
Immunity/Limited Liability was analyzed as a single intervention in the state law assessment (any immunity provision present) as well as broken out by specific type of entity offered immunity that includes trained and untrained lay rescuers, AED premise owners, and use trainers.

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Summary of PAD Interventions in State Laws

As of June 30, 2017, all states had PAD law in effect. Four states authorized all seven evidence-informed interventions and the majority of states authorized some combination of “best” and “promising quality” interventions. Three states authorized lay bystander limited liability only, a “promising” intervention.

View maps of PAD interventions addressed in state law and detailed tables of PAD interventions and legal authorities by state.

Targeted AED Site Placement

On June 30, 2017, 38 states had laws supporting targeted AED placement. Of these, 37 required or authorized specific locations to have an AED onsite, including:

Schools (25)
Health, fitness, and/or athletic facilities (15)
State-owned or occupied facilities (10)
Gambling venues (2)
Public golf courses (1)

Nineteen states required or encouraged AED placement at a clearly marked and/or easy-to-access location in the event someone goes into cardiac arrest. For example, Louisiana requires higher education athletic departments competing in intercollegiate sports to place an AED on the premises of the athletic department in an open-view, easy-to-access location that is within two feet of a telephone to call 9-1-1.

Training Anticipated Responders

Forty-five states’ laws included AED use training for anticipated lay responders who are likely to be present during an OHCA event. Examples of these laws include:

Colorado requires that all entities acquiring AEDs ensure that expected users receive training on AED use through a course that meets nationally recognized standards and is approved by the Colorado Department of Public Health and Environment.
Florida requires that all state parks and schools with AEDs ensure that employees or volunteers expected to use an AED receive appropriate training on its proper use.
Rhode Island, Illinois, and New York require AED use training as a condition of civil immunity.

AED Training Graduation Requirements

Thirty states have laws requiring or encouraging AED use training for middle school, high school, or an unspecified grade level. The 2015 IOM report recommended including AED use training in high school or middle school as a graduation requirement.⁴

Examples of these laws:

Colorado allows local education providers to apply for grants to provide instruction to students in grades 9 through 12 on AED use that must be nationally recognized and evidence-based.
Starting in the 2013–2014 school year, Georgia requires that local boards of education provide students in grades 9 through 12 with instruction on AED use through existing health and physical education courses.

EMS and Medical Coordination

Forty states have laws on PAD program EMS coordination. Of these, 33 states’ law established an AED registry and/or required entities that sell, supply, or acquire an AED to provide notification of the AED to an EMS system. Law in 29 states also requires the person who uses an AED during a medical emergency to call 9-1-1 and activate an EMS system.
Law in 22 states includes both an AED registry and a requirement for EMS notification of placement and requires activation of EMS when AEDs are used during medical emergencies.

Examples of these laws:

Delaware requires the state’s EMS medical director to maintain a file containing the name of each person or entity that acquires an AED with state funding.
Massachusetts requires those who possess AEDs to notify the local police and their EMS provider of the number, type, and location of AEDs in their possession.

Response Plans and Continuous Quality Improvement

Of the 23 states that have laws on PAD emergency response plans, 20 require or encourage the plan to be written or formalized and four require or encourage the plan to be practiced.

A total of 12 states include laws on quality improvement planning and/or review of AED use incidents to improve PAD programs and evaluate their effectiveness.

Examples of these laws:

Iowa requires AED program grant recipients to submit an annual report to the state health department indicating the number of AED uses, patient outcomes, and number of individuals trained.
Ten states require both AED response and quality improvement planning.
Fewer than half of states (20) require or encourage a licensed health care provider or other medical authority to oversee PAD programs.
In 19 states, each clinical use of an AED must be reported to EMS, a licensed health care provider, or other medical authority or entity. For example, Arizona requires the submission of a written report to the state’s Bureau of Emergency Medical Services & Trauma System within five working days after an AED’s use.

AED Routine Maintenance and Testing

In 42 states, the law requires or encourages the maintenance and testing of AEDs.

Examples of these laws:

Nevada specifically requires maintenance and testing of AEDs located in airports, high schools, and state-owned or -occupied facilities.
Georgia and Texas require maintenance and testing of AEDs located in schools.

Limited Liability

All states provide some form of civil liability or qualified immunity protection for AED users acting in good faith and as a reasonably prudent person would act in similar circumstances. In 48 states, untrained lay rescuers receive protection, and civil immunity is only provided to trained lay rescuers in three states.

Other common groups afforded limited liability include the following:

Persons or entities that provide AED training (37 states)
PAD site owners, managers, or lessees (30 states)
AED acquirers not required to obtain an AED (entities not required by law to have an AED on-site) (19 states)
Mandated AED acquirers (entities required by law to have an AED on-site) (18 states)
PAD program directors (12 states)

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Implications and Trends in PAD Law Adoption, 2010–2017

Since 2010, several states have enacted laws with evidence-informed PAD program interventions.¹ Between 2010 and 2017, the number of states with laws addressing two of three interventions with “best” evidence ratings (i.e., high-quality evidence and strong potential public health impact) increased from 29 to 38 for targeted site placement and from 43 to 45 for training anticipated responders.

In addition, more states have enacted two of the four interventions with “promising” evidence ratings: from 15 to 23 states with emergency response plan law and from 39 to 42 for routine AED maintenance and testing law. In 2017, four states authorized all seven evidence-informed interventions, 29 authorized all three “best” interventions, nine authorized all four “promising” interventions, and three authorized lay bystander limited liability only, a “promising” intervention.

This analysis also shows the growing number of PAD program interventions within schools. There is consensus on the importance of AED placement and use training in schools.^{4, 18–24} Schools are the most common locations required by state law to have AEDs on site (25 states). Thirty states now also have an AED training graduation requirement codified in law; between January 1, 2015, and June 30, 2017, alone, five states enacted graduation requirements (Kentucky,³⁴ Montana,³⁵ New Mexico,³⁶ South Carolina,³⁷ and Tennessee³⁸) and one state’s law changed from encouraging AED training to requiring it for graduation (South Dakota³⁹).

Although there has been growth in the enactment of evidence-informed PAD interventions, state PAD laws continue to vary, and the presence of several interventions has decreased in recent years. Since 2010, the number of states with AED registry/EMS location notification law dropped from 35 to 33; states with EMS activation law fell from 33 to 29; states with PAD program medical oversight law fell from 21 to 20; states with clinical use reporting law fell from 22 to 19; and states with quality improvement plan law fell from 13 to 12.

Given the changing landscape of state PAD laws and the persistently high mortality rates among people experiencing OHCA in public settings, further studies are needed to understand the actual impact of variations in state PAD law on OHCA outcomes. Outcome data that may be used to evaluate this association include the Cardiac Arrest Registry to Enhance Survival (CARES).⁴⁰ CARES collects OHCA outcome measures from EMS systems in 35 states with a catchment area representing 25% of the U.S. population. These types of evaluations may help identify which PAD program elements are associated with increased lay bystander AED use, which could inform efforts to improve OHCA survival rates and related health outcomes.

Disclaimer: This fact sheet presents a summary of Public Access Defibrillation laws in effect as of June 30, 2017, and is not intended to promote any particular legislative, regulatory, or other action. For more information on State Law Fact Sheets, see the Policy Resources page.

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Kentucky Laws ch. 70 SB 33 (2016).
Montana Laws ch. 190 SB 135 (2017).
New Mexico Laws ch. 17 HB 104 (2016).
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Tennessee Laws ch. 677 SB 2088 (2016).
South Dakota Laws ch. 75 SB 140 (2017).
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