Are AEDs within health clubs lifesavers or liabilities?
It's a club's worst nightmare. A member suddenly collapses during a workout and doesn't respond to CPR. That was the scene at TCA's Midtown Athletic Club in Rochester, NY, four years ago when an athletic, middle-aged father of two passed out while running on the treadmill. After calling 911, a personal trainer retrieved the club's automated external defibrillator (AED) and rushed over to the victim, whose heart had stopped beating. A doctor and a nurse, who happened to be working out at the club at the time of the emergency, placed the AED's electrodes on the man's chest and delivered an electric shock.
The member survived because an AED was used within minutes of the cardiac arrest, says Glenn William, general manager of the 125,000-square-foot multipurpose club.
“He would not have had a chance at all without the AED,” William says.
About 340,000 Americans die from sudden cardiac arrest (SCA) each year, and some of these incidents occur within fitness facilities. If fitness professionals use AEDs within the first minute of a SCA, they can increase their members' survival rate by up to 90 percent. A victim's chances of survival drop 7 percent-10 percent for every minute without defibrillation, and more than 95 percent of cardiac arrest victims die before reaching the hospital, according to the American Red Cross. Even though some clubs may perform CPR on a cardiac arrest victim, call 911 and wait for the ambulance to arrive, the defibrillation may be delivered too late to ensure survival. CPR can keep the blood circulating, but only an AED can deliver the shock necessary to restart the heart during ventricular fibrillation, a short-circuiting of the heart that prevents the heart from effectively pumping oxygen to the brain.
The American Heart Association estimates that at least 20,000 lives could be saved each year by the prompt use of AEDs, which were once used primarily by paramedics but are now being deployed to public locations like airports and health clubs. Nine states have passed legislation requiring health clubs to install AEDs (see map on p. 24), and many more states will require them in the future, says Richard Lazar, president and CEO of AED Risk Insights, a Portland, OR-based firm that provides information about AED laws and legislation. Health clubs that lack emergency equipment or employ staff untrained in CPR or AED use face legal consequences or fines if one of their members is not treated for cardiac arrest on site. For example, a Florida health club without an on-site AED settled a lawsuit for $2.25 million when a 42-year-old member fell into a coma after a cardiac arrest. Florida is not one of the nine states requiring the placement of AEDs in health clubs, yet the plaintiff argued that the community expected the club to have an AED. The International Health, Racquet and Sportsclub Association counters that no legal standard of care exists requiring AEDs to be in all health clubs, but Lazar says lawyers are increasingly identifying health clubs as a target in AED cases.
“The health club industry is under fire, and it is more difficult for clubs to argue they do not have a duty to buy AEDs,” he says. “Legal duty arises in two ways — a legislature passes a mandate or a standard of care develops. Clubs may come kicking and screaming, but juries, judges and legislatures are arguing that a standard of care should emerge that requires health clubs to have AEDs whether they want to or not.”
Since 1996, the number of AEDs distributed annually has increased from 20,000 to 200,000. Many club owners, however, aren't installing AEDs in their clubs for two reasons — cost and liability.
Clubs can expect to pay on average $1,500 to $2,000 to buy an AED and about $35 to $100 per employee for training costs. Training employees in the proper use of an AED and making them aware of its location is just as important as having an AED on site, Lazar says. For example, Town Sports International (TSI) saved six lives in 18 months by not only deploying AEDs to all 141 of its clubs but also by empowering its employees and others to serve as responders in an emergency.
All of Midtown's employees are trained in CPR, and the 34 members of William's management team became certified to use an AED via a two-hour CPR/AED course offered by the American Heart Association. The AED training and certification costs $37 per employee, he says.
Nonprofit fitness facilities also are investing in AEDs and training employees to use them. The Saddleback Valley YMCA in Mission Viejo, CA, recently bought two AEDs, has installed them in visible locations and requires its staff to be trained in AED use and get refresher training every three to six months.
“Although they are very easy to use, it is good, like with CPR training, to carry out in-house training and dummy incidents and scenarios to keep staff on their toes and confident in safety issues,” says Bex Conran-Dunham, the Saddleback Valley Y's associate executive director.
Beyond the cost for training employees to use an AED and the purchase cost of the device, fitness facilities must invest in maintaining the AED. Fitness facilities typically pay between $75 and $230 every two to five years to replace the lithium batteries and $40 to $170 every two years to replace the electrode pads, which stick to the victim's chest, according to the American Red Cross.
“The gel needs to have enough thickness to conduct the electrical current,” says Kathryn Danaher of the American Red Cross' Michigan chapter. “If it doesn't, it won't be able to analyze the heart rhythm, and it would never get to the point of providing a shock to the victim.”
To avoid such a scenario at his health club, William makes sure the AEDs are serviced twice a year, the electrode pads are replaced annually and the batteries are replaced every three to four years.
“They're used on average once every five years, and with all the staff and member turnover in a health club, you need to find a way to have a sustainable AED program,” he says.
Clubs also must stay on top of AED recalls. Even if a health club changes the batteries and regularly maintains an AED, the device can still fail under dire circumstances due to a malfunction. Between 1996 and 2005, the Food and Drug Administration issued 52 advisories for AEDs. Most of those recalls involved moisture or corroded wiring, and only a handful involved AEDs that didn't work, says Paul Weinberg, a lawyer for Weinberg and Garber, P.C., who has represented four families in AED lawsuits against clubs.
“The number of failures given the number of AEDs is miniscule,” he says.
By having an AED on site, a club reduces its risk of being sued, but if it doesn't maintain its AED or act responsibly in an emergency, the club could be worse off than it was to begin with, Lazar says. The federal Cardiac Arrest Survival Act provides some protection under the Good Samaritan law to businesses that buy an AED and to rescuers, but it doesn't guarantee protection, Lazar says.
“The perception that Good Samaritan laws will protect AED users is not always the case,” he says. “One should not assume that you have guaranteed protection as an AED user today.”
In some cases, victims still die from a cardiac arrest despite the rescue efforts of fitness professionals in health clubs. The combination of CPR and AED use doubles a victim's survival rate as compared to CPR alone, but less than a quarter of victims were saved when the rescuers used an AED and CPR, according to a 2004 study published in the New England Journal of Medicine. In other words, individuals who go into cardiac arrest have a 75 percent chance of dying even if an AED and CPR are used in the emergency.
“The public is under the perception that the devices are magic bullets,” says Brian Heermance, a partner in the New York office of Morrison Mahoney LLP, who has represented several clients in the health and fitness industry. “If you have one and use it, they think they'll survive, but the study shows that's not the case.”
Other public venues, such as airports, malls, public sports facilities, golf courses, ferries and train terminals have a higher incidence of cardiac arrests than health clubs, according to a report titled, “Public Locations of Cardiac Arrest — Implications for Public Access Defibrillation.” However, the chance of experiencing a cardiac arrest increases 20 times during and after vigorous exercise, says Michael Danko, a lawyer for O'Reilly and Danko, who has represented plaintiffs in cases against 24 Hour Fitness.
“You're going to have an extremely high number of cardiac arrests in clubs, which is why they need AEDs,” Danko says.
However, another study in the New England Journal of Medicine found that one sudden death occurs per 1.51 million episodes of exertion at a health club, and another study found that less than 15 percent of all cardiac arrests occur in public venues. Most happen at home, Heermance says.
“It's remote [to have a heart attack in a club],” he says. “The literature shows that the best chance of having one is at home. Even ordinary activities like shoveling snow can get the heart pumping.”
While some club owners may be concerned about the cost-effectiveness or usefulness of an AED, others may resist purchasing an AED because they think it will be difficult to use in an emergency. The argument that AEDs are hard to use, however, is a non-issue, Lazar says.
“Even untrained sixth graders can use the AED within 90 seconds,” he says. “I've never heard of where one was misused.”
With a voice prompt, an AED walks a rescuer through the necessary steps and indicates when to press the shock button, stand clear and check the heart. The computerized medical device, which is about the size of a phone book, analyzes the heart rhythm and advises the rescuer when a shock is needed or not needed.
“It's completely idiot-proof,” William says. “You can't shock someone who doesn't require a shock.”
In 1998, Midtown became the first club in New York to have an AED. Now, all 12 of the TCA facilities nationwide have at least one AED on site.
“We decided that the benefits of AEDs far outweighed the downside, and it was in our members' best interest to get these,” says William, who first read about the benefits and liabilities of AEDs in the New York Times and organized a meeting with an AED manufacturer at TCA's headquarters in Chicago eight years ago. “We all worry about liability, but in this case, it made a lot of sense.”
The Indian Creek Racquet Club, a TCA club in Overland Park, KS, with 1,000 members, stores an AED in an office shared by the tennis pros and membership director. Every two years, all 50 employees are trained to use the AED in an on-site AED/CPR class offered by the American Heart Association. While the club isn't required by Kansas law to have an AED, Indian Creek has seen an increase in business due to having the on-site AED.
“I've had three people ask me if we had an AED on site because they had a heart condition,” says Brad Houx, membership director. “From a business standpoint, it helps that we have one available.”
Health clubs without AEDs on site may be targets for wrongful death lawsuits if a cardiac arrest occurs at their facility. Just ask the nation's two largest fitness chains — Bally Total Fitness and 24 Hour Fitness — which have both been sued by family members of cardiac arrest victims who died at their clubs. In a case that has yet to go to trial, a mother of a 46-year-old land surveyor filed a lawsuit against Bally after her son died from a cardiac arrest at a Gaithersburg, MD, club. According to the complaint, bystanders performed CPR until the paramedics arrived. When the EMS team delivered the first AED shock, it was too late, and the man died.
“Bally decided in 2002 to put in AEDs throughout the country, but only in places where they were required to do so,” says Weinberg, who is representing the mother of the victim. “According to testimony from other cases where they were deposed, they saw the problem clearly and decided to fight the legislation mandating AEDs in health clubs.”
Bally has since installed an AED in the club and is deploying AEDs at clubs nationwide.
In another court case, a mother sued a Los Angeles 24 Hour Fitness club after her son suffered from a cardiac arrest during his workout. The 41-year-old allegedly got off the treadmill and collapsed. A member later found him, and an employee began CPR. When the victim began to vomit, resuscitation efforts ceased while the employees searched for a mask. The paramedics arrived 11 minutes after they were called, but it was too late to revive him, Danko says. When the case was taken to trial, the judge dismissed it based on a release that the member had signed.
“The membership contract contained a standard clause releasing the club from liability for negligence,” says Danko, who appealed the ruling. “Our position was that under California law, you don't release gross negligence to not have the AEDs that are standard in the industry.”
California health clubs are now required by law to have AEDs on site by July 2007, and 24 Hour Fitness has complied by deploying the devices in not only its California clubs, but also in all 360 clubs in 13 states, says Shannon May, spokesperson for 24 Hour Fitness.
Some other large health club chains like Gold's Gym are also opting to place AEDs in their clubs nationwide as part of their corporate policy. Gold's 47 corporate-owned clubs in Washington, DC; San Antonio; St. Louis; and Los Angeles all have AEDs, and some of the chain's franchisee-owned clubs are starting to install AEDs as well, says Dave Reiseman, spokesperson for Gold's. Deploying AEDs is a way for club chains like 24 Hour Fitness to provide an effective emergency response to their members and guests in their time of need, May says.
At least one 24 Hour Fitness club has already used an AED to save a member's life. However, the deployment of the AEDs at 24 Hour was too late to save many other cardiac arrest victims, Danko says, referring to the fitness chain's opportunity to participate in an AED program five years ago. As part of the program, a manufacturer offered to train the 24 Hour Fitness employees how to use the device and provide some AEDs free of charge, he says.
“The cost of AEDs at that time was $1,600, which was less than the cost of an exercise bike,” he says. “AEDs are also fool-proof. If someone has a cardiac arrest, CPR is extremely ineffective, and an AED is very effective. Without an AED, in the event of cardiac arrest, the victim faces pretty close to certain death.”
William knows this all too well. After losing two members who suffered from cardiac arrests on the tennis courts, the club's management team installed one AED 100 feet from the tennis courts and another between the cardio area and the fitness room. Since then his staff has saved the lives of two of its members — a man in his mid-50s and an 18-year-old woman with a heart abnormality.
While some club owners view AEDs as lifesavers, others consider them liabilities. Regardless of their stance on the AED debate, however, more health clubs are being required by law to have AEDs on site, train their employees, maintain the devices and act properly in an emergency to keep their members' hearts pumping and serve as an effective link in the chain of survival.
Recently, New Jersey, Michigan, California, Oregon, Rhode Island, Louisiana, New York, Arkansas and Illinois have passed legislation mandating the placement of AEDs in health clubs.
The laws in New Jersey, Michigan, California, Oregon, Rhode Island, Arkansas, Louisiana and Illinois provide clubs with liability protection.
The New York law excludes clubs with fewer than 500 members.
Legislation requiring AEDs in fitness centers was passed in Suffolk County, NY; Weston, FL; and Montgomery County, MD.
Legislation is pending in Connecticut, Missouri, Kentucky and Washington, DC. Massachusetts is also considering a bill to require AEDs in every club in the state as well as staff AED training.
Cardiac arrests, which are the number one killer in the United States, can strike individuals of any age or gender, but they most commonly happen to men over the age of 50. A cardiac arrest can strike one of your members suddenly and without warning. Here are some of the symptoms.
Cardiac arrest victims often collapse and pass out due to a lack of blood flow to the brain and other vital organs.
Victims also often have no pulse, stop normal breathing, and their fingers, toes and lips can turn blue.
Source: American Heart Association
Develop a written emergency policy and review it every three months. Fitness facilities should determine where the AED will be placed within the facility, address the internal and external emergency notification systems, follow an AED maintenance schedule and have periodic AED drills.
Identify your response team members, and have them trained to do CPR and use an AED. To find classes near your club, check the Web sites for the American Red Cross (www.redcross.org), the American Heart Association (www.americanheart.org), the American Safety and Health Institute (www.ash.org), EMP/America/Medic First Aid (www.medicfirstaid.us) or the National Safety Council (www.nsc.org).
Review your state laws regarding AEDs. Laws vary from state to state, and some laws require nationally recognized training, coordination with emergency medical services, medical direction or record keeping. For more information on state laws, visit www.ncsl.org/programs/health/aed/htm.
Keep a phone close to the AED so responders can quickly call 911. To save time, place a disconnected but charged cell phone inside the cabinet housing the AED.
Make the AED visible in the facility. Put AED signs at the entrance of the club and above the AEDs. Also mention that your club has AEDs in your member newsletter, and discuss how to use them in an emergency. Don't keep your AED in a locked office or storage room. Otherwise, it may be inaccessible in an emergency.