Is It Time to Revisit OSHA Requirements/Guidance on CPR in the Workplace?

On January 2, 2023, spectators and horrified TV viewers witnessed a workplace cardiac arrest when Buffalo Bills safety Damar Hamlin collapsed on the football field. On any given NFL gameday, there are at least 27 medical personnel, including paramedics and an “airway physician”-anesthesiologist and/or emergency medicine physician available on the field or in the stadium. Therefore, Mr. Hamlin received immediate cardiopulmonary resuscitation (CPR), shock delivered by an automated external defibrillator (AED), rapid intubation, and ventilation with 100% oxygen. He was transported to the hospital after 19 minutes (Novak, 2023) and survived with no evident adverse outcomes identified to date. Most workers who suffer cardiac arrest do not receive the same care as that received by Mr. Hamlin.

While more than 350,000 people in the United States experience out-of-hospital cardiac arrest per year, only up to 10% of them survive (American Heart Association, 2023). Ten thousand of those cardiac arrests occur in workplaces (3%) (Occupational Safety and Health Administration [OSHA], 1970). In a recent meta-analysis of studies of cardiac arrest (An et al., 2022), those who received CPR within 5 minutes were 2½ times more likely to have return of spontaneous circulation (ROSC) compared with those who received CPR after 5 minutes. Also, those who received CPR for less than 15 minutes were more than 4 times more likely to experience ROSC compared with those who received CPR for more than 15 minutes. Access to defibrillation increased ROSC, with those who received defibrillation more than twice as likely to experience ROSC compared with those who did not receive defibrillation.

Findings from this study have clear implications for managing cardiac arrest in the workplace. Rapid access to CPR and defibrillation is a critical component in increasing workers’ chances of surviving cardiac arrest. Yet, OSHA guidelines for the provision of CPR and AED in the workplace are inconsistent with these findings. Employees, specifically in commercial diving (OSHA, 1970a), logging operations (OSHA, 1970b), permit-required confined spaces (OSHA, 1970c), and electrical power generation, transmission, and distribution (OSHA, n.d.), must be trained in first aid and CPR. In the OSHA general duty clause, it is recommended, but not required, that someone is trained and able to provide first aid and CPR. Furthermore, the guidance states that if the worksite is “in proximity” to a clinic, hospital, or emergency service, this will meet the recommendation. Although there is no response time associated with this guidance, in other correspondence, OSHA stated that “in proximity” meant 2 to 3 minutes. Not only is it concerning that there is no specific requirement, but the expectation also that an external facility/service could respond and initiate CPR within 5 minutes is unrealistic. At this time, OSHA does not provide requirements or direct guidance regarding the use of AEDs in the workplace; it formed a partnership with the American College of Occupational and Environmental Medicine (ACOEM) to have access to their resources and AED use guidelines (Starr, 2012). Based on the most recent evidence available regarding factors that promote survival in cardiac arrest, current OSHA guidance and regulations seem insufficient to provide optimum protection of workers. Also, there is disparity in the existing requirements, with some work groups having the benefit of required CPR training, while most workers do not have that same benefit. For these reasons, it seems appropriate for the American Association of Occupational Health Nurses (AAOHN) Board of Directors to at least review this issue and determine whether it wishes to join forces with other relevant ally organizations to petition OSHA to modify requirements so that more workers have access to CPR and AED and an increased chance of surviving cardiac arrest.