AEDs, Like Fire Extinguishers, Should Be in Every School, Say Experts

Many schools across the United States and Canada don’t have an automated external defibrillator (AED) on-site, but calls for mandatory policies are mounting. The benefits, say experts, would go far beyond the schools themselves.

While sudden cardiac death in young people is rarer than in adults, it’s not nonexistent, with estimates suggesting the incidence ranges from less than one to four sudden cardiac deaths per 100,000 children and adolescents.

“It’s a small number, but it’s catastrophic when it occurs,” electrophysiologist Jason Andrade, MD (University of British Columbia, Vancouver, Canada), told TCTMD. “It’s catastrophic to the family. It’s catastrophic to everyone else around them, particularly because it’s something that’s still preventable.”

A high school in Vancouver recently raised money to buy an AED after a student collapsed and died in 2022 from sudden cardiac arrest. The fundraising effort gained national media attention after the school board said they couldn’t install it because of concerns that it would be inequitable for one school to have an AED and not others. In response, British Columbia’s education minister said she supports placing the devices in all provincial schools, and the Vancouver school board has requested provincial funding to move forward with doing so.

“The best chance you can give someone to survive a sudden cardiac is to have early access to an AED,” said Andrade. “These devices need to be placed where they are most likely to be needed in order to maximize the survival of people who have a cardiac arrest. If an AED is readily available 70% of kids will survive a sudden cardiac arrest. If there isn’t an AED available, the survival of out-of-hospital cardiac arrest is horrifically low. So, it’s a low-risk/high-reward intervention.”

Ankur Doshi, MD (University of Pittsburgh, PA), an emergency medicine specialist with a research interest in sudden cardiac arrest, said that even though it is a “rare-frequency event,” having AEDs available in schools could save not just the life of a student, but a teacher, bus driver, custodian, or anyone else in the vicinity who collapses.

“If AEDs are this mystical, mysterious kind of thing, and somebody needs to use it, there’s a lot of fear for the bystander,” he told TCMD. “If they’re readily accessible and something we practice and know about from the time we’re in grade school, then it stands to reason—we don’t have this data, I can’t prove it—that the fear may go away a little bit.”

Steve Lin, MD (Unity Health Toronto, Canada), another emergency physician whose research aims to improve outcomes in sudden cardiac arrest, also emphasized the importance of making automated defibrillators accessible to school-age kids.

“If you were going to mandate CPR training in high school in Ontario, you should also have AEDs in the schools,” he told TCTMD. “I think there’s only an upside to it. We do know when a child usually has a sudden cardiac arrest, they need good CPR and an AED—it’s just the type of arrest they go into. It tends to be an electrical issue with their heart and really the only way to break that cycle is with defibrillation.”

Still Waiting on Provincial Details

In Ontario, Bill 141 is known as the Defibrillator Registration and Public Access Act, and it’s aimed at improving cardiac emergency responses across the province. Initially passed in 2020, Bill 141 requires that all public facilities have an AED on-site and that staff members are trained to use it. While some public spaces are obvious, such as community centers, sports arenas, and swimming pools, experts are still awaiting guidance around what constitutes “designated premises” outlined in the bill.  

If AEDs are this mystical, mysterious kind of thing, and somebody needs to use it, there’s a lot of fear for the bystander. Ankur Doshi

Right now, nobody knows if elementary and high schools would be considered a public space and mandated to have AEDs in place, said Katherine Allan, PhD (Unity Health Toronto). Both Allan and Lin, along with cardiologist Paul Dorian, MD (Unity Health Toronto), are the co-investigators of a national network investigating the scope of sudden cardiac arrest across Canada.

“During the committee hearings for Bill 141, we proposed there should be regulations to designate where AEDs should be placed, but to date we haven’t seen any released yet,” said Allan. “They only just recently announced, right before Christmas, who they had chosen to be the actual provincial registrar, but that’s really the only action that has happened in the 4 years since the bill has been passed.”

She noted that some regional emergency medical services (EMS) agencies have placed AEDs in schools, and that the Heart & Stroke Foundation of Canada had previously issued grants to subsidize the cost of installing the devices in public spaces, including schools.

“Until the regulations come out [from Bill 141] and are publicized and enforced, there really isn’t any mandate making them available in public spaces,” said Allan. “We actually don’t even have a good sense of how many AEDs are out there right now in Ontario. What generally happens is that each EMS agency has their own list of the AEDs in their region, but they don’t necessarily share all that data.”   

As part of Bill 141, the province will also require that publicly accessible AEDs be registered, and there are plans to create a centralized database that can be accessed by responders—both the public and emergency services—to help find the devices quickly. The registry will allow researchers to track outcomes and to assess how the devices are being used, said Allan.

Across Canada, the installation of AEDs in schools varies province by province. For example, a law in Manitoba was passed more than a decade ago that required “high-traffic public places,” including elementary, junior, and high schools, to have an AED. In many of the smaller provinces, such as Nova Scotia, Newfoundland and Labrador, New Brunswick, and Prince Edward Island, there are AEDs in all public schools.

In other Canadian provinces, such as Alberta, AEDs aren’t mandatory in schools, but some have them as a result of efforts by school boards. Other provincial governments have said they back plans to have them installed. In Quebec, for example, the ministry of education announced plans in 2024 to install AEDs in all public schools, including primary schools, high schools, vocational training centers, and adult education facilities.

Situation in the US

In the US, blanket policies supporting AEDs in schools vary by state, with roughly half having legislation in place: there is no federal law mandating them across the country. There is legislation requiring AEDs in all schools in Alabama, Georgia, Florida, Arkansas, California, New York, and Ohio, among others, while some states have AED-related laws, such as requiring them on-site for school practices and athletic events.

In late 2024, former President Joe Biden signed the HEARTS Act to boost cardiopulmonary resuscitation and AED training. As part of the act, which is not a federal mandate, schools can apply for grants to purchase AEDs and develop emergency action plans (EAPs) that can be implemented in response to a sudden cardiac arrest.

“The hope is that, I think, this will work very much in concert with states passing statewide legislation for more mandatory laws,” Jonathan Kim, MD (Emory School of Medicine, Atlanta, GA), told TCTMD.

Kim, who spearheaded the drive in Georgia to make AEDs mandatory in all public schools from kindergarten to grade 12, also highlighted the work of the Smart Hearts Coalition, which was created in 2023 following the collapse of National Football League (NFL) player Damar Hamlin from sudden cardiac arrest.

The coalition, which is backed by the NFL and other major sports organizations, in addition to the American College of Cardiology and American Heart Association, advocates for best practices to prevent deaths from sudden cardiac arrest. This includes the development of an EAP that is widely distributed, posted, and rehearsed; clearly marked AEDs at athletic venues where high school practices or competitions are held (or within 1 to 3 minutes of the venue); and CPR and AED education for coaches.

“There’s really a big push in the US right now,” said Kim. “I really do credit Damar [Hamlin] quite a bit. I mean, these are issues that are certainly not new in the sports cardiology world. We’ve been pushing for AEDs and focusing on EAPs forever really, but there’s a reason why all of a sudden there’s so much interest from the political space, which is ultimately what you need. In the last year-and-a-half there’s been tremendous gain, but clearly we have a long way to go.” 

The Smart Hearts Coalition focuses primarily on high schools, but this at least knocks off the low-hanging fruit, said Kim.

“Obviously, you want to start to hit tangible goals and not aim for too much all at once,” said Kim. “It’s wonderful that there’s such emphasis on athletes, on sports cardiology, but kids who aren’t athletes can have sudden cardiac arrest, too. This isn’t just an athlete’s affliction. These should be everywhere.”

Barriers to Implementation

Allan highlighted lack of education as a key roadblock to implementation, noting that sudden cardiac arrest isn’t fully understood by the public or media. “Heart attack” is frequently used interchangeably with sudden cardiac death, and while most people are familiar with CPR, they’re less so with AEDs.

“We know from looking at EMS data in Ontario that AEDs are used about 2% of the time,” she said. “There’s a lack of awareness. It’s something we struggle with—how do we get people’s attention? How do we talk about these things in a world where you’re being bombarded with so much information all the time.”

In addition to education, Andrade said the three biggest “pushbacks” to widespread implementation come down to cost, maintenance, and training. While costs might be a legitimate concern, training people how to use AEDs shouldn’t be holding things up.

“We learned basic life support in school,” he said. “Training in how to use an AED isn’t all that special. They exist with the express intent that they are to be used by bystanders who have no training outside of knowing where the AED is located, and that they need to get it. These devices  tell you exactly how to use them, shouting the commands as they walk you through their use. They also have diagnostic and safety features. They’re designed to ensure a bystander isn’t going to harm anyone with an AED.”

To TCTMD, Kim stressed the importance of developing an EAP, which includes mundane details such as knowing when the batteries were last changed and carrying out safety drills. While many efforts around AEDs in school focus on getting the devices into place, it’s the practice that matters most.

Kids who aren’t athletes can have sudden cardiac arrest, too. This isn’t just an athlete’s affliction. Jonathan Kim

“In Georgia public schools, there’s eight fire drills per school year, roughly one per month,” said Kim. “There hasn’t been a child who’s died from a fire in Georgia since the 1940s. There are kids that have sudden cardiac arrest every day in this country.  It’s also one thing to have the AED at the school, but if you don’t know what you’re doing with it, or how to get everybody mobilized, this is an issue as well.”

Doshi noted that people feel more comfortable using a fire extinguisher than they would an AED, mostly because they see them everywhere. If elementary-age children were exposed and trained in using an AED, that comfort gets passed down to the next generation.

“I think most of it comes down to education,” said Doshi. “If you teach all the middle school [kids] to do this, and then there will be high schoolers who know how to do this, and then there will be adults. They’re going to forget how to do it, but they won’t be scared of it.”

Kim believes there aren’t any downsides to having AEDs in schools. For all the debates in the sports cardiology world, there’s absolutely none about the importance of developing an EAP with an AED in place, he said.

“Nobody argues this point,” said Kim. “There’s absolutely 100% consensus in the medical world about the importance of this.”