Clinical paper| Volume 164, P4-11, July 2021

Effectiveness of public-access automated external defibrillators at Tokyo railroad stations



      To investigate the effectiveness of public-access automated external defibrillators (AEDs) at Tokyo railroad stations.


      We analysed data from a population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan (2014–2018). We identified patients aged ≥18 years who experienced bystander-witnessed cardiac arrest due to ventricular fibrillation of presumed cardiac origin at railroad stations. The primary outcome was survival at 1 month after cardiac arrest with favourable neurological outcomes (cerebral performance category 1–2).


      Among 280 eligible patients who had bystander-witnessed cardiac arrest and received defibrillation at railroad stations, 245 patients (87.5%) received defibrillation using public-access AEDs and 35 patients (12.5%) received defibrillation administered by emergency medical services (EMS). Favourable neurological outcomes at 1 month after cardiac arrest were significantly more common in the group that received defibrillation using public-access AEDs (50.2% vs. 8.6%; adjusted odds ratio: 11.2, 95% confidence interval: 1.43–88.4) than in the group that received defibrillation by EMS. Over a 5-year period, favourable neurological outcomes at 1 month after cardiac arrest of 101.9 cases (95% confidence interval: 74.5–129.4) were calculated to be solely attributable to public-access AED use. The incremental cost-effectiveness ratio to gain one favourable neurological outcome obtained from public-access AEDs at railroad stations was lower than that obtained from nationwide deployment (48.5 vs. 2133.4 AED units).


      Deploying public-access AEDs at Tokyo railroad stations presented significant benefits and cost-effectiveness. Thus, it may be prudent to prioritise metropolitan railroad stations in public-access defibrillation programs.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Chan P.S.
        • McNally B.
        • Tang F.
        • Kellermann A.
        Recent trends in survival from out-of-hospital cardiac arrest in the United States.
        Circulation. 2014; 130: 1876-1882
        • Gräsner J.T.
        • Wnent J.
        • Herlitz J.
        • et al.
        Survival after out-of-hospital cardiac arrest in Europe—results of the EuReCa TWO study.
        Resuscitation. 2020; 148: 218-226
        • Kiyohara K.
        • Kitamura T.
        • Sakai T.
        • et al.
        Public-access AED pad application and outcomes for out-of-hospital cardiac arrests in Osaka, Japan.
        Resuscitation. 2016; 106: 70-75
        • Kitamura T.
        • Iwami T.
        • Kawamura T.
        • Nagao K.
        • Tanaka H.
        • Hiraide A.
        Nationwide public-access defibrillation in Japan.
        N Engl J Med. 2010; 362: 994-1004
        • Weisfeldt M.L.
        • Sitlani C.M.
        • Ornato J.P.
        • et al.
        Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million.
        J Am Coll Cardiol. 2010; 55: 1713-1720
        • Valenzuela T.D.
        • Roe D.J.
        • Nichol G.
        • Clark L.L.
        • Spaite D.W.
        • Hardman R.G.
        Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.
        N Engl J Med. 2000; 343: 1206-1209
        • Hallstrom A.P.
        • Ornato J.P.
        • Weisfeldt M.
        • et al.
        Public-access defibrillation and survival after out-of-hospital cardiac arrest.
        N Engl J Med. 2004; 351: 637-646
        • Page R.L.
        • Joglar J.A.
        • Kowal R.C.
        • et al.
        Use of automated external defibrillators by a U.S. airline.
        N Engl J Med. 2000; 343: 1210-1216
        • Caffrey S.L.
        • Willoughby P.J.
        • Pepe P.E.
        • Becker L.B.
        Public use of automated external defibrillators.
        N Engl J Med. 2002; 347: 1242-1247
        • Capucci A.
        • Aschieri D.
        • Piepoli M.F.
        • Bardy G.H.
        • Iconomu E.
        • Arvedi M.
        Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation.
        Circulation. 2002; 106: 1065-1070
        • Kitamura T.
        • Kiyohara K.
        • Sakai T.
        • et al.
        Public-access defibrillation and out-of-hospital cardiac arrest in Japan.
        N Engl J Med. 2016; 375: 1649-1659
        • Bardy G.H.
        • Lee K.L.
        • Mark D.B.
        • et al.
        Home use of automated external defibrillators for sudden cardiac arrest.
        N Engl J Med. 2008; 358: 1793-1804
        • Kronick S.L.
        • Kurz M.C.
        • Lin S.
        • et al.
        Part 4: systems of care and continuous quality improvement: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S397-413
      1. Part 4: the automated external defibrillator: key link in the chain of survival. European Resuscitation Council.
        Resuscitation. 2000; 46: 73-91
        • Deakin C.D.
        • Anfield S.
        • Hodgetts G.A.
        Underutilisation of public access defibrillation is related to retrieval distance and time-dependent availability.
        Heart. 2018; 104: 1339-1343
        • Tokyo Statistical Yearbook
        Tokyo Metropolitan Government.
        (Accessed 13 July 2020, at
      2. Policy Bureau. Ministry of land, infrastructure, transport and tourism. (Accessed 13 July 2020, at

        • Tama Area Databook, Statistical Table
        The Institute for Tokyo Municipal Research.
        (Accessed 13 July 2020, at
        • Nolan J.P.
        • Hazinski M.F.
        • Billi J.E.
        • et al.
        Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
        Resuscitation. 2010; 81: e1-25
        • Hazinski M.F.
        • Nolan J.P.
        • Aickin R.
        • et al.
        Part 1: executive summary: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
        Circulation. 2015; 132: S2-39
        • White Paper on Tokyo Fire Service
        Tokyo Fire Department.
        (Accessed 13 July 2020, at
      3. AED Map. Japan Foundation for Emergency Medicine. (Accessed 1 June 2020, at

        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).
        Circulation. 2004; 110: 3385-3397
      4. Team RC. R: a language and environment for statistical computing. R Foundation for Statistical Computing. (Accessed 31 October 2018, at

        • Gianotto-Oliveira R.
        • Gonzalez M.M.
        • Vianna C.B.
        • et al.
        Survival after ventricular fibrillation cardiac arrest in the Sao Paulo metropolitan subway system: first successful targeted Automated External Defibrillator (AED) program in Latin America.
        J Am Heart Assoc. 2015; 4e002185
        • Folke F.
        • Lippert F.K.
        • Nielsen S.L.
        • et al.
        Location of cardiac arrest in a city center: strategic placement of automated external defibrillators in public locations.
        Circulation. 2009; 120: 510-517
        • Kuramoto N.
        • Morimoto T.
        • Kubota Y.
        • et al.
        Public perception of and willingness to perform bystander CPR in Japan.
        Resuscitation. 2008; 79: 475-481
        • Waalewijn R.A.
        • Nijpels M.A.
        • Tijssen J.G.
        • Koster R.W.
        Prevention of deterioration of ventricular fibrillation by basic life support during out-of-hospital cardiac arrest.
        Resuscitation. 2002; 54: 31-36
        • Eftestøl T.
        • Wik L.
        • Sunde K.
        • Steen P.A.
        Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest.
        Circulation. 2004; 110: 10-15
        • Christenson J.
        • Andrusiek D.
        • Everson-Stewart S.
        • et al.
        Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.
        Circulation. 2009; 120: 1241-1247
        • Valenzuela T.D.
        • Roe D.J.
        • Cretin S.
        • Spaite D.W.
        • Larsen M.P.
        Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model.
        Circulation. 1997; 96: 3308-3313
        • Takei Y.
        • Nishi T.
        • Matsubara H.
        • Hashimoto M.
        • Inaba H.
        Factors associated with quality of bystander CPR: the presence of multiple rescuers and bystander-initiated CPR without instruction.
        Resuscitation. 2014; 85: 492-498
        • Smith C.M.
        • Lim Choi Keung S.N.
        • Khan M.O.
        • et al.
        Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review.
        Eur Heart J Qual Care Clin Outcomes. 2017; 3: 264-273
        • Masterson S.
        • McNally B.
        • Cullinan J.
        • et al.
        Out-of-hospital cardiac arrest survival in international airports.
        Resuscitation. 2018; 127: 58-62
        • Sondergaard K.B.
        • Hansen S.M.
        • Pallisgaard J.L.
        • et al.
        Out-of-hospital cardiac arrest: probability of bystander defibrillation relative to distance to nearest automated external defibrillator.
        Resuscitation. 2018; 124: 138-144
        • Aufderheide T.
        • Hazinski M.F.
        • Nichol G.
        • et al.
        Community lay rescuer automated external defibrillation programs: key state legislative components and implementation strategies: a summary of a decade of experience for healthcare providers, policymakers, legislators, employers, and community leaders from the American Heart Association Emergency Cardiovascular Care Committee, Council on Clinical Cardiology, and Office of State Advocacy.
        Circulation. 2006; 113: 1260-1270
        • Inokuchi R.
        • Sato H.
        • Maehara H.
        • Iwagami M.
        Association between railway station characteristics and the annual incidence of automated external defibrillator use in the station: analysis of data from the Yamanote Line in Tokyo.
        Resuscitation. 2019; 145: 79-81
        • Zijlstra J.A.
        • Bekkers L.E.
        • Hulleman M.
        • Beesems S.G.
        • Koster R.W.
        Automated external defibrillator and operator performance in out-of-hospital cardiac arrest.
        Resuscitation. 2017; 118: 140-146
      5. Sakamoto T, Marukawa S, Nagao K, et al. Study report subsidized by the Health Labour Sciences Research Grant. National Institute of Public Health. (Accessed 14 July 2020, at

        • Andersen L.W.
        • Holmberg M.J.
        • Granfeldt A.
        • James L.P.
        • Caulley L.
        Cost-effectiveness of public automated external defibrillators.
        Resuscitation. 2019; 138: 250-258