ISE05/18-19

• Cardiac arrest is the abrupt loss of heart function in a person who may or may not have been diagnosed with heart disease. It is often fatal if not treated immediately. While out-of-hospital cardiac arrest ("OHCA") cases might be more severe in the absence of health care providers for immediate treatments, members of the public at the scene (i.e. bystanders) could play a critical role in early rescue of the victims.^{1Legend symbol denoting According to the American Heart Association ("AHA"), a strong Chain of Survival which includes: (a) recognition of cardiac arrest and activation of the emergency response system; (b) early cardiopulmonary resuscitation with an emphasis on chest compressions; (c) rapid defibrillation; (d) basic and advanced emergency medical services; and (e) advanced life support and post-cardiac arrest care, can improve chances of survival and recovery for victims of cardiac arrest. In addition, lay rescuers (i.e. bystanders) can contribute in the first three steps. See AHA (2019).} Against this, many places in the world have been developing their strategies in promoting bystander intervention in such medical emergencies, particularly on their knowledge/skills and willingness to help.
• According to a study conducted by the medical school of the University of Hong Kong in 2015, the survival rate of OHCA cases in Hong Kong was only 2.3%, which was in the lower range among the major Asian cities.^{2Legend symbol denoting This study was a retrospective analysis of the prospectively collected data on OHCA managed by the emergency medical services from 1 August 2012 to 31 July 2013 where 5 154 cases were analysed. See Hong Kong Medical Journal (2017).} Some commented that this might partly be due to the low availability of automated external defibrillators ("AEDs") in the public and the lack of knowledge about AED by the general public.^{3Legend symbol denoting See香港01 (2018).} On the other hand, some viewed that bystanders might be discouraged from helping the OHCA victims due to the potential legal litigation resulted from suboptimal resuscitation effort initiated.^{4Legend symbol denoting See Resuscitation Council of Hong Kong (undated).} Currently, there is no legislation in Hong Kong which provides for the exemption of rescuers from legal liabilities that might be incurred in performing first aid.
• In contrast to Hong Kong, some places have enacted legislation to provide the legal protection to the bystanders. There are also new initiatives introduced to promote bystander intervention in medical emergencies, including crowdsourcing life savers from the public and enhancing relevant education and training to the public. This issue of Essentials presents an overview and recent developments of bystander intervention in medical emergencies in Hong Kong, followed by a discussion on the new measures or trend seen in various overseas places (e.g. Singapore and the United States) in terms of: (a) technology adoption, (b) education and training, and (c) legislation to promote bystander intervention in medical emergencies.

Promoting bystander intervention in medical emergencies in Hong Kong

• In Hong Kong, the Government and various charitable organizations (e.g. Hong Kong St. John Ambulance and Hong Kong Red Cross) have been offering courses to teach people the knowledge of cardiopulmonary resuscitation^{5Legend symbol denoting It is an emergency life-saving procedure performed when the heart stops beating.} ("CPR") and the operation of AED. Among them, the Hong Kong Fire Services Department ("HKFSD") has trained over 32 000 people under its community CPR training courses since 1999.^{6Legend symbol denoting See GovHK (2018a).} Besides, it has launched the Heart Saver Scheme since 2007 which allows members of the public with valid qualifications to operate AED to join the Scheme, encouraging them to proactively render assistance to people suffering from cardiac arrest.^{7Legend symbol denoting By the end of 2017, a total of 8 391 qualified persons have been appointed as "Heart Savers". See HKFSD (2017).}
• A survey conducted by the medical school of the University of Hong Kong revealed that nearly all respondents from the public would call for help in an OHCA event.^{8Legend symbol denoting This study was a face-to-face semi-structured questionnaire survey conducted to the members of the public on weekdays between 2 November 2015 and 15 December 2015 where 401 of them were interviewed. See Hong Kong Medical Journal (2016).} Despite this, only one-fifth of them would commence CPR or apply an AED to the victim if it is available. Against this backdrop, the medical school of the University has indeed initiated a series of community projects, such as the development of mobile application ("app") (for locating AEDs in the public and providing information on CPR) and e-learning platform, and promotion of compression-only/hands-only CPR (i.e. without month-to-mouth breath) teaching in secondary schools.
• Nonetheless, new initiatives led by the Government to promote bystander intervention appear rather limited. Recently, the Government has introduced a character named "Anyone" to promote to the public the message that "anyone can save lives" which has aroused great public attention. The message is supported by the organization of related training courses to the public. In some overseas places, apart from offering training courses, they have taken a step further to bring additional measures/initiatives to promote greater participation and facilitate more efficient access to the necessary equipment by the public.

Technological adoption for shortening the rescue time

• In recent years, mobile apps have been increasingly adopted in overseas places for crowdsourcing life savers to respond to OHCA cases. For instance, the Singapore government launched a mobile app called "myResponder" in 2015 which allows members of the public who are at least 18 years of age or with parental consent to register as Community First Responders ("CFRs") voluntarily.^{9Legend symbol denoting It is to encourage individuals who are trained in CPR and AED skills to register as CFRs but it is not a prerequisite of the registration. See Singapore Civil Defence Force (2018) and Singapore Civil Defence Force (2019).} Connected with the emergency medical services system and the national AED registry^{10Legend symbol denoting It is a database of AED locations in public places which is also open to public.}, the app alerts CFRs to any potential cardiac arrests within 400 metres and the nearest available AEDs.^{11Legend symbol denoting Besides, a three-year pilot programme called "AED on Wheels" has been introduced where AEDs are installed in 100 taxis. When cardiac arrest cases take place, the app will alert the taxi drivers (who were trained in CPR and have the knowledge to use an AED) within 1.5 kilometres to deliver the AED to the scene and provide appropriate assistance. See Info-communications Media Development Authority, Singapore (2016).} CFRs who choose to respond can then proceed to the stated location and assist by performing CPR or applying an AED to help the victim prior to the arrival of the emergency medical services. While CFRs may not be trained in CPR/AED, they may help locate and retrieve the nearest AED using the public AED registry, or assist based upon the guidance of emergency call operators. As at June 2018, there were more than 26 000 registered CFRs and around 1 700 of them had responded to the notifications.^{12Legend symbol denoting See Government Technology Agency, Singapore (2018)., 13Legend symbol denoting Apart from crowdsourcing CFRs to respond to OHCA cases, the app launched a new function in April 2018 which alerted the CFRs for the nearby minor fire cases (e.g. those break out in rubbish chutes or bins) and encouraged them to extinguish the fire using available means.}
• Other places have similarly made use of mobile apps to help save lives through technology. For instance, in the United Kingdom, the London Ambulance Service has partnered with an application developer on the use of the emergency alert app called "GoodSAM"^{14Legend symbol denoting Partnering with over 80 organizations around the world with some of them being local ambulance services (e.g. Ambulance Victoria and St John New Zealand), the app is also operating in different large cities (e.g. Melbourne and Auckland). See GoodSAM (2019a).}. When an emergency call of life-threatening nature is received, the emergency service centre will send the details through the GoodSAM app to alert the nearest registered volunteer responder. If the responder is available, he/she can accept the alert via the app and make their way to the location of the incident. Registered responders are those who can provide basic life support and first aid with valid proof of relevant qualifications (e.g. doctor, nurse, paramedic or a registered first aider).^{15Legend symbol denoting See GoodSAM (2019b).} The app also features the "Instant on Scene" function which allows staff of the emergency services to see the victim at the scene for early assessment from the smartphone camera of the responder. Riding on the video streaming, the app is claimed to have the function to remotely measure the victim's pulse.^{16Legend symbol denoting See GoodSAM (2019a).}
• Apart from the adoption of mobile apps, some overseas places are trying out other innovative means to increase the emergency service efficiency. For example, drones (i.e. unmanned aircraft) are being explored as an alternative way to deliver medical services to the public.^{17Legend symbol denoting A preliminary study conducted by a medical university in Sweden in June 2017 found that it was possible to autonomously transport and deliver an AED using a drone in out-of-sight flights and drones carrying AEDs may reduce time to defibrillation in OHCAs. See Jama Network (2017).} In the City of Reno of the United States, for instance, it announced in September 2018 that it had successfully completed the trial of drone delivery of AEDs with a drone delivery company in a national pilot programme and they would continue to work with the authorities to secure necessary regulatory approvals.^{18Legend symbol denoting See City of Reno, the United States (2018).} Whether it will be accepted as a regular service and gain popularity remain to be seen in the future.

Education and training initiatives for increasing the skills of the public

• Many countries, in particular in Europe, are seen to have made first-aid education mandatory for primary and/or secondary schools, including Germany, France, Denmark and Norway.^{19Legend symbol denoting See International Federation of Red Cross and Red Crescent Societies (2015).} More recently in July 2018, the Department of Education of the United Kingdom decided to make health education compulsory in all schools across the country starting from September 2020.^{20Legend symbol denoting See Department for Education, the United Kingdom (2018b).} Under the draft statutory guidance, secondary school students should be taught of life-saving skills, including how to administer CPR, as well as the purpose of defibrillators and when one might be needed.^{21Legend symbol denoting See Department for Education, the United Kingdom (2018a).}
• Some countries even mandate first-aid training as one of the prerequisite for driving. In order to qualify for a driving theory test in Switzerland, applicants must prove that they have participated in a course on life-saving measures approved by the Federal Roads Office of the Swiss government within six years of the application.^{22Legend symbol denoting This is based on the unofficial translation of information of the Article 10 of the Regulation on the Admission of Persons and Vehicles to Road Traffic in Switzerland. For details, please see the official website of the Swiss government (2019).}
• Apart from compulsory education and training, some places have developed new tools to increase the public interest in learning CPR. For example, the American Heart Association ("AHA") in the United States has introduced interactive kiosks at the public places (primarily at the airports) since June 2013 to promote the hands-only CPR training to the public.^{23Legend symbol denoting The training takes about five minutes. Each kiosk has a touch screen that shows a short instructional video, followed by a practice session and a 30-second test. With the help of a practice manikin, the kiosk gives precise training feedback about the depth and rate of compressions, which are the factors that influence the effectiveness of CPR. See AHA (2018).} As at the first half of 2018, there were more than 30 kiosks across the country and over 100 000 people have been trained through the kiosks with the help of a practice manikin. A recent research funded by AHA supported that the kiosk was same effective as a 30-minute classroom training led by an instructor for hands-only CPR education.^{24Legend symbol denoting See Annals of Emergency Medicine (2018).} Similar initiative is also seen in Singapore. Since September 2018, it has been launching such kind of self-learning kiosks at the public places (e.g. shopping malls and cinemas), with hopes to help the community build up its capabilities in CPR and AED skills, and ultimately increase the bystander response rate.^{25Legend symbol denoting See Singapore Heart Foundation (2019).}

Legal protection and liability for the bystanders

• Technological adoption, as well as education and training initiatives, may increase the public's knowledge, awareness and participation in the OHCA cases. Nevertheless, as mentioned above, there is concern that people might be deterred from helping OHCA victims due to the fear of risk and/or liability. To encourage more people to offer emergency aid, there have been suggestions of introducing a "Good Samaritan" law to exempt rescuers from legal liabilities in emergency situations. In response to two Legislative Council Questions about the possibility of enacting such kind of legislation, the Government has responded that whether such legislation is necessary and suitable requires thorough discussion and consideration of different factors, such as public awareness of heart attack and their knowledge of the first aid for it.^{26Legend symbol denoting See GovHK (2018a) and GovHK (2018b).}
• In many overseas places, they have enacted similar laws to give legal protection to bystanders against being sued for making mistakes in the course of rescue. Yet there are variations in the extent of protection among these places. For instance, in California of the United States, protection is generally given to anyone who renders emergency care or treatment by the use of an AED at the scene of an emergency.^{27Legend symbol denoting Section 1714.21(b) of the Civil Code of California states that "any person who, in good faith and not for compensation, renders emergency care or treatment by the use of an AED at the scene of an emergency is not liable for any civil damages resulting from any acts or omissions in rendering the emergency care."} While in Queensland of Australia, statutory protections for voluntary aid in emergency are applied only to certain groups of people (e.g. medical practitioners, nurses).^{28Legend symbol denoting See Section 26 of Queensland Government (2019a) and Section 16 of Queensland Government (2019b).} There is no statutory immunity for untrained persons to perform voluntary aid in emergency.
• In contrast to the above approach, some places have introduced laws stipulating the duty to rescue another person when the bystander is able to provide necessary assistance without risking anyone. In other words, citizens have a legal duty to provide an "easy" rescue (e.g. offering or calling for aid) for those in peril. For instance, in Germany, its Criminal Code stipulates that a person who does not render necessary assistance during accidents or a common danger or emergency, particularly when it is safe to do so, shall be liable to punishment.^{29Legend symbol denoting See Section 323c of German Government (2019).} Recently, there has been enforcement seen.^{30Legend symbol denoting Three people in the western German city of Essen were imposed fines for ignoring an elderly man who collapsed next to bank cash machines. See BBC News (2017).} Nevertheless, imposing such a "duty to rescue" on bystanders appears less common around the globe, as opposed to exempting rescuers' liability through the "Good Samaritan" law.^{31Legend symbol denoting See CPR Heart Center (2019).}

Concluding remarks

• When cardiac arrest takes place, every second counts. Contrary to Hong Kong where offering training courses remains the major means of promoting bystander intervention, different places such as Singapore, the United Kingdom and the United States have extended the efforts by developing new measures to encourage the community to contribute to saving lives prior to the arrival of the emergency medical services. These included crowdsourcing the life savers from the mobile app, mandating relevant education/training in schools, launching interactive self-learning kiosks at convenient public places, and/or increasing the legal protection to the bystanders. These initiatives might be conducive to increasing people's knowledge and raising their willingness to provide voluntary aid when an OHCA emergency arises.

Prepared by Kent CHUNG
Research Office
Information Services Division
Legislative Council Secretariat
28 February 2019