September 18, 2001

Honorable John Henshaw
Assistant Secretary of Labor
Occupational Safety and Health Administration
Washington, DC 20210

Dear John:

     The purpose of this letter is to draw your attention to a promising lifesaving technology, automatic external defibrillators (AEDs), and request that you consider whether promotion of AEDs should be elevated to a priority at the Occupational Safety and Health Administration.

     When used promptly and properly, AEDs can be used to increase the rate of survival after cardiac arrest. A recent survey article in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION concluded that: AThe AED represents an efficient method of delivering defibrillation to persons experiencing out-of-hospital cardiac arrest and its use by both traditional and nontraditional first responders appears to be safe and effective.@

     Recent articles in the NEW ENGLAND JOURNAL OF MEDICINE examined the effectiveness of AED programs in different settings. One study documented a 38% effectiveness rate in lifesaving among 148 people who suffered cardiac arrest in casinos. The other study documented a 17% AED effectiveness rate in lifesaving when available on 627,956 American Airline flights with trained flight attendants.

     AEDs cost about $3,000 plus maintenance costs, primarily for batteries, of about $150 per year. A recent study in CIRCULATION found that untrained sixth graders following automated voice prompts performed almost as well in use of AEDs as well trained emergency medical technicians or paramedics. Nevertheless, for organizations that commit to AED use, there is also an incremental cost of training personnel for proper use of this technology.

     In a recent editorial in the NEW ENGLAND JOURNAL OF MEDICINE, Dr. Marie Robertson noted that only 2 to 5% of the 225,000 persons who have sudden and unexpected cardiac arrest each year outside a hospital are successfully resuscitated compared to the 17 to 38% success rates found with AEDs. I do not know how many of these cases of sudden cardiac arrest occur in the workplace but it seems that this is a worthwhile question to investigate. One of my senior staff members, John Morrall, has performed some preliminary cost-effectiveness calculations and determined that AEDs in the workplace might prove to be a very cost-effective intervention.

     If you should determine that this matter is a priority for OSHA, a number of questions will need to be investigated. The National Institute for Occupational Safety and Health, through its surveillance resources, may be able to determine the incidence of sudden cardiac arrest in the workplace. A survey of small and large private employers might need to be conducted to determine the extent of AED use in US workplaces and barriers to increased AED use.

     I am aware that steps have been taken by other federal agencies to promote use of AEDs. On April 12, 2001, after OMB review, the US Department of Transportation issued a final rule (proposed in the previous Administration) that requires AEDs on all those air carriers for which at least one flight attendant is required. The accompanying regulatory impact analysis indicated that about nine lives per year would be saved, producing $25.2 million in annual benefits compared to $2.4 million in annual costs. It has also been brought to my attention that the Department of Health and Human Services and the General Services Administration have jointly developed guidelines for public access to AEDs in public buildings. The guidelines, which were published in the FEDERAL REGISTER on May 23, 2001, were developed pursuant to a May 19th 2000 Presidential memorandum. Although these steps are promising, I am not aware of any steps by the Federal government to promote the use of AEDs in private workplaces.

     If you should decide that the AED issue is worthy of investigation, a series of complex questions will need to be addressed. For example, the cost-effectiveness of AED availability will depend on how many AEDs are provided in a workplace setting and what the incremental effectiveness rate for multiple AEDs proves to be. Moreover, an important question is whether AED use should be promoted by information, economic incentives, voluntary agreement, or compulsory regulation.

     In requesting that OSHA consider making AEDs a priority for promotion, I understand that OSHA faces limited resources, legislative constraints, and numerous areas where steps can be taken to enhance the health and safety of workers. At this stage, I am simply asking OSHA to consider whether this matter should be a priority in the foreseeable future. I would appreciate an initial response to this inquiry within 60 days. Please do not hesitate to contact me or John Morrall if you would like to discuss this matter further.



John D. Graham
Office of Information and Regulatory Affairs