Public Access Defibrillation: Advances From Japan

Hideo Mitamura


Nat Clin Pract Cardiovasc Med. 2008;5(11):690-692. 


First-time visitors to Japan might be surprised to see a vending machine containing an automated external defibrillator (AED; Figure 1A). This interesting innovation is just one of the ways in which AED use in Japan is being increased. Until just a few years ago, public access to AEDs was something that the Japanese medical profession would not have thought possible. A change in Japanese law in 1991 allowed paramedics to defibrillate patients at the scene of an out-of-hospital cardiac arrest. Contrary to expectation, however, this approach was not satisfactory. According to a report from Osaka Prefecture (population 8,800,000), the survival at 1 year for witnessed out-of-hospital cardiac arrests was 3.0% during the period 1999–2001.[1] Defibrillation was given at a median of 11.5 min after the emergency call in the third year (2001), which was too late to improve survival. Survival decreases by 7–10% for each minute between cardiac arrest and defibrillation;[1] it is clear, therefore, that shock has to be delivered before the arrival of paramedics, which is only possible with AED use by a lay witness. Changing the rescue system paradigm was not easy, however, and the way that Japan has dealt with this problem could serve as a reference for other countries.

Figure 1.

Cost-saving automated external defibrillator storage. (A) Vending machine. (B) Advertising box.

The recommendation for public use of AEDs in the 2000 international guidelines for resuscitation[2] was not readily accepted in Japan. One of the barriers to the use of AEDs by lay people was article 17 of Japanese Medical Practitioner Law, which stipulates that only qualified doctors are permitted to carry out medical procedures, including the use of AEDs. The first step forward was made in April 2001, when the US Federal Aviation Administration made AEDs mandatory on all US domestic and international flights. Japan Airlines, the country's leading airline, could not ignore this message and, by the end of 2001, the Japanese government allowed aircraft to be equipped with an AED and for flight attendants to be trained to use the device. The use of AEDs by the general public was, however, still prohibited and unnecessary deaths continued to occur. The most publicized death was that of Prince Takamado, a member of the Imperial family, who collapsed in September 2002 while playing squash. At that time, unlike flight attendants, ambulance crews were not permitted to defibrillate patients, and even paramedics had to obtain permission from a doctor in the control center before using an AED. In order to remove obstacles preventing immediate defibrillation, the medical community and the media worked together to highlight the importance of public access defibrillation. Under increasing pressure from doctors, as well as from the strength of public opinion, in July 2004 the government finally authorized the lay use of AEDs.

The subsequent dissemination of AEDs in Japan has been amazingly rapid. AED sales increased dramatically from 3,607 in 2004 to 35,170 in 2006, making Japan the second largest market for AEDs after the US. Increasingly, the devices are being placed in public buildings, including airports, train stations, schools, hotels, shopping centers, sports complexes, temples, and sento (public bathhouses). Even some vehicles, such as sightseeing buses and taxis, now carry AEDs, with the drivers trained to use them. The success of AED dissemination in Japan was seen at the 2005 World Expo held in Aichi Prefecture. AEDs were placed at 300 m intervals across the event site and, during a period of 6 months, four individuals who experienced sudden cardiac arrest were successfully resuscitated. Notably, however, the dissemination and placement of public access AEDs in Japan has not been guided by government policy, but rather by the voluntary involvement of individual organizations and business owners.

According to an interim report from the Japanese Fire and Disaster Management Agency,[3] 18,320 people suffered a witnessed out-of-hospital cardiac arrest in 2006. Lay rescuers used AEDs in 140 individuals, of whom 45 (32.1%) were still alive at 1 month, indicating that public use of AEDs could potentially save the life of one in three patients with out-of-hospital sudden cardiac arrest. By contrast, there were 18,180 individuals with sudden cardiac arrest who did not receive defibrillation from a member of the public, of whom 1,509 (8.3%) survived. Public use of AEDs could, therefore, achieve a fourfold increase in survival.

Unique concepts and ideas are being employed to expand public use of AEDs in Japan. Vending machines containing an AED are situated in locations where people congregate and, therefore, where the chance of a cardiac arrest being witnessed is high.[4] The AED is installed behind an unlocked, transparent door fitted with an alarm (Figure 1A). The cost of keeping an AED in a vending machine is primarily covered by the revenue from drink purchases and is shared by the manufacturer of the drink, the provider of the machine, the distributor of the AED, and the proprietor who provides the space and electricity. Allowing paid advertising on a display panel above a box housing an AED (Figure 1B) is another method of funding public access AEDs. Again, the proprietor has only to provide the space and electricity. These creative efforts are surely effective in keeping down AED dissemination costs.

Another recent innovation has helped increase public access to AEDs; internet-based maps showing the location of AEDs have been produced for several cities in Japan (Figure 2A-C).[5] The maps can be magnified to display AED locations more precisely, and even where the devices are situated inside buildings (Figure 2B). Moreover, this information can be accessed using a cellular phone (Figure 2C), which if equipped with a global positioning system function, is able to guide the individual to the closest AED in the area.

Figure 2.

Automated external defibrillator (AED) map on the internet. (A) Each red dot represents an AED location in Aichi Prefecture. (B) A magnified view showing AEDs (red hearts) within buildings. (C) Display of AED location on the screen of a cellular phone. Images adapted from Aichi Prefecture AED maps []. Permission obtained from Fire Prevention and Industrial Safety Division, Disaster Prevention Office, Aichi Prefecture, Japan.

Despite these remarkable accomplishments, during 2006 public use of AEDs took place in just 140 of 18,320 witnessed out-of-hospital sudden cardiac arrests, less than 1% of all cases.[3] We are still faced with problems, such as a lack of easily accessible AEDs, particularly in rural areas, a lack of awareness of the function, benefit, presence, or feasibility of the devices, and, more importantly, hesitation in the lay person's mind about using an AED. In December 2007, local government in Yokohama City enacted an ordinance mandating AEDs in certain public buildings. The Japan Advertising Council has begun to place promotional advertisements for public use of AEDs in various newspapers. To relieve lay citizens of their anxiety, the Japanese government has formally declared that an individual's liability is limited, irrespective of the outcome of resuscitative efforts (Civil Code 698). A teaching course is provided for lay volunteers at local fire stations or branches of the Japanese Red Cross. The Japanese Foundation for Emergency Medicine and the Japanese Heart Foundation are also actively involved in increasing public awareness of and access to AEDs. Notably, the liability for training in the use of AEDs has been waived, a policy that has previously been demonstrated to be reasonably effective in Piacenza, Italy.[6] The simplicity and safety of modern AEDs are such that legally limiting their use to trained individuals would be a disadvantage.

The aversion to giving mouth-to-mouth ventilation, even when pocket masks are included in the AED case, is another barrier to bystander-initiated resuscitation. Promoting ventilation as an option, rather than a requirement, could alleviate this problem.[7] Two recent studies have demonstrated that resuscitation efforts with chest compression alone are similarly effective to those with chest compression plus mouth-to-mouth ventilation.[8,9] With this simplified technique, lay rescuers might be less reluctant to provide basic life support plus AED use.

Although Japan did not introduce public access AEDs until after many Western countries, creative measures, such as vending machine AED access, AED maps on the internet, and reduced barriers to public AED use, represent a step forward. Japan has learnt from Western countries, and now advances from Japan should, in turn, be shared with the rest of the world.

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