Abstract
Background
Efforts to guide automated external defibrillator (AED) placement for out-of-hospital cardiac arrest (OHCA) treatment have focused on identifying broadly defined location categories without considering hours of operation. Broad location categories may be composed of many businesses with varying accessibility. Identifying specific locations for AED deployment incorporating operating hours and time of OHCA occurrence may improve AED accessibility. We aim to identify specific businesses and municipal locations that maximize OHCA coverage based on spatiotemporal assessment of OHCA risk in the immediate vicinity of franchise locations.
Methods
This study was a retrospective population-based cohort study using data from the Toronto Regional RescuNET Epistry cardiac arrest database. We identified all non-traumatic public OHCAs occurring in Toronto, Canada from Jan. 2007–Dec. 2015. We identified 41 unique businesses and municipal location types with 20 or more locations in Toronto from the YellowPages, Canadian Franchise Association, and the City of Toronto Open Data Portal. We obtained their geographic coordinates and hours of operation from websites, phone, or in-person. We determined the number of OHCAs that occurred within 100 m of each location when it was open (spatiotemporal coverage) for Toronto overall and downtown. The businesses and municipal locations were then ranked by spatiotemporal OHCA coverage. To evaluate temporal stability of the rankings, we calculated intra-class correlation (ICC) of the annual coverage values.
Results
There were 2,654 non-traumatic public OHCAs. Tim Hortons ranked first in Toronto covering 286 OHCAs. Starbucks ranked first in downtown covering 110 OHCAs. Coffee shops and bank machines from the five largest Canadian banks occupied eight of the top 10 spots in both Toronto and downtown. The rankings exhibited high temporal stability with ICC values of 0.88 (95% CI, 0.83–0.93) in Toronto and 0.79 (95% CI, 0.71–0.86) in downtown.
Conclusions
We identified and ranked businesses and municipal locations by spatiotemporal OHCA risk in their immediate vicinity. This approach may help policy makers and funders to identify and prioritize potential partnerships for AED deployment in public access defibrillator programs.
Keywords: Cardiac arrest, Automated external defibrillator, Resuscitation
Subject Terms: Cardiopulmonary Resuscitation and Emergency Cardiac Care, Cardiopulmonary Arrest
Introduction
Use of automated external defibrillators (AEDs) has been shown to increase survival after sudden cardiac arrest by reducing the delay to treatment and allowing for rapid defibrillation.1–5 As such, AEDs are disseminated through public access defibrillation (PAD) programs to encourage bystander response in communities worldwide.6, 7 However, even with the increasing effort and resources devoted to these programs, bystander AED use remains low.8–10 This is a prominent health concern as out-of-hospital cardiac arrest (OHCA) is associated with a less than ten percent survival rate and about 400 000 deaths in North America alone.11, 12
Efforts to improve AED use have initially focused on identifying locations with high spatial OHCA risk, such as office buildings or shopping malls, for targeted AED placement.13–19 The use of spatial OHCA risk has led to the development of optimization models which demonstrate that locations for AED placement can be prioritized to efficiently target OHCA hotspots.20 However, temporal availability of AEDs was not considered in these studies and is rarely considered when deciding where to place the AEDs. Previous work done by our group and others has demonstrated that AEDs placed in locations that are not accessible 24 hours a day significantly reduce the potential usefulness of AEDs.21, 22 Optimizing AED locations with knowledge of temporal availability could mitigate the loss of coverage associated with building hours of operation.22
We hypothesized that the next step to improve AED placement in existing PAD programs is to examine the potential impact of a strategy that entails partnership with franchise businesses for broad deployment of AEDs. Developing partnerships with franchise businesses can be extremely beneficial to PAD programs as they may provide financial support to purchase and distribute the AEDs as well as improve awareness of AED locations through marketing campaigns connected with their brand.
The goal of this study is to determine and rank order the spatiotemporal OHCA risk in the immediate vicinity of specific businesses and municipal locations in Toronto, Canada for the purpose of evaluating AED deployment potential to support the development of private-public PAD partnerships. This study extends previous research that focused only on spatial OHCA risk in broad location categories, by examining both spatial and temporal OHCA risk, as well as more granular location types including individual businesses and municipal locations. Using these rankings, policy makers and funders can identify the best organizations to seek partnership with to maximize OHCA coverage of AEDs placed in their locations. We hypothesized that certain franchise businesses would be more advantageous than others for this purpose because of their locations and opening hours in relation to actual spatiotemporal cardiac arrest risk.
Methods
Study Design and Setting
This was a retrospective population-based cohort study using data from the Toronto Regional RescuNET cardiac arrest database, Rescu Epistry, which is compliant with the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest database and the Strategies for Post Arrest Care database; the methodologies of these two databases are described elsewhere.23, 24 Approval for this study was obtained from the St. Michael’s Hospital Research Ethics Board and no informed consent for participants was required.
We included all non-traumatic, public-location OHCA episodes that occurred in Toronto from January 2007 – December 2015. Public locations included airports, heliports, construction sites, office buildings, medical offices, industrial sites, mining sites, railways, streets, hotels, restaurants, bars, casinos, shopping malls, single stores, strip malls, schools, recreation facilities, sports fields, parks, stadiums, golf courses, and dockyards, and excluded hospitals and nursing homes. Geographical data for the location of each OHCA episode, namely street address and latitude-longitude coordinates, were converted to the Universal Transverse Mercator (UTM) format.
A list of registered AEDs, as of March 2015, was obtained from Toronto Paramedic Services. The data set contains 912 publicly and privately owned AEDs that are registered with the owner’s consent, located in 737 unique addresses. AED registration is voluntary in Toronto. For each AED, the address, location type, and hours of operations were detailed.
Data Collection for businesses and municipal locations
The businesses and municipal locations included in this study were identified from the Canadian Franchise Association (CFA), YellowPages and the City of Toronto’s Open Data Portal.25–27 The CFA is the Canadian franchise industry’s sole recognized national trade association. It produces an annual franchise directory with up-to-date information on current franchisees, including the number of locations in Canada, USA, and internationally. YellowPages provides a comprehensive directory of restaurants, shops, and services in major cities worldwide. Listings are obtained through phone companies and are verified by a YellowPages data quality team. The Toronto Open Data Portal is part of Toronto’s Open Data initiative to make data available for any public use such as research, website and mobile app development, and data visualization. The Open Data Portal is maintained by the City of Toronto and contains the address, phone number, facility name, and facility type for municipally operated services in categorized datasets. Information on the portal is collected and maintained by municipal staff.
All franchises in the CFA directory with more than 20 locations in Toronto were included. Similarly, all stores or businesses listed in YellowPages with more than 20 locations in Toronto were included. Finally, all datasets in the Toronto Open Data Portal in the “business”, “locations and mapping”, and “parks and recreation” categories with 20 or more entries were included. Next, we gathered the addresses of each location from either YellowPages, Google, or via the official company website. Each address was then converted to UTM format and plotted using a geographic information system (QGIS - v2.4.0, Open Source Geospatial Foundation, Beaverton, OR) to ensure the locations were inside the Toronto boundaries. In total, we identified 41 businesses and municipal locations, totaling 4,949 individual facilities (see Supplemental Table 1 for a summary of the included businesses and municipal locations). Businesses that were typically only accessible through a larger building, such as restaurant chains found exclusively in shopping mall food courts, were excluded from the study. We categorized and examined the businesses and municipal locations for both downtown Toronto, as defined by the City of Toronto28, and Toronto as a whole.
We gathered the hours of operation of each facility through online resources, by phone, or in-person visits. Hours of operation could not be confirmed for 91 of the 223 Separate Schools (i.e. religious schools) and 453 of the 952 Automated Teller Machines (ATMs) included in this study. For these location types, we assumed hours of operation based on collected/known hours of operations for facilities in the same location type. The assumed hours used were 8:00am – 5:00pm for Separate Schools and 8:00am – 11:00pm for in-branch ATMs. We conducted sensitivity analyses (Supplemental Material Section 1.2, Supplemental Tables 2 – 7) to examine the impact of the assumed hours on OHCA coverage.
Analysis
Analysis 1: Ranking businesses and municipal locations by spatiotemporal OHCA coverage
For each of the 41 businesses and municipal locations, we calculated the following data elements using all public non-traumatic OHCAs: the total number of their facilities; the total number of OHCAs that occurred within 100m of any of their facilities (“assumed 24/7 coverage”); the total number of OHCAs that occurred within 100m of their facilities and when the respective facility was open based on its hours of operations (“actual coverage”); the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage (“coverage loss”), the actual coverage divided by the number of facilities (“coverage efficiency”). Cardiac arrest coverage was calculated independently for each of the 41 businesses and municipal locations. Therefore if an OHCA was covered by two different businesses, it was counted as a covered OHCA for both businesses. The 100m coverage radius (109.4 yards) was based on American Heart Association recommendations and a three minute response goal.7, 29, 30
We repeated the coverage analysis using only OHCAs that were not already covered by the existing registered AEDs in Toronto. In other words, all OHCAs that occurred within 100m of a registered AED while the AED was available, based on hours of operation of the buildings housing the AED, were excluded from this analysis.
Analysis 2: Temporal stability of the businesses and municipal location coverage rankings
To measure the variation in the rankings over time, we separated the cardiac arrest data by year of occurrence and calculated the actual coverage provided by each business and municipal location in each year. We then computed the intra-class correlation (ICC) of the annual values and a corresponding 95% confidence interval using a two way random effect model, ICC(C,1), as defined by McGraw et al31.
Analysis 3: Ranking broad location categories by spatiotemporal OHCA coverage
To enable comparisons with other studies and for generalizability, the 41 businesses and municipal locations were grouped into one of 14 broader location categories and the same metrics from Analysis 1 were recalculated. We also repeated this coverage analysis using only OHCAs that were not already covered by the existing registered AEDs in Toronto.
Results
Characteristics of cardiac arrest episodes
A total of 27,650 non-traumatic OHCAs occurred from January 2007 – December 2015 in the city of Toronto. Of these, 2,654 occurred in a public setting with 506 of them occurring in the downtown area. The characteristics of the included public cardiac arrests are summarized in Table 1.
Table 1.
Characteristics of included public cardiac arrests.
| Characteristic* | All included Toronto cardiac arrests occurring in a public location (n=2654) | All included Downtown Toronto cardiac arrests occurring in a public location (n=506) |
|---|---|---|
| Average age ±SD | 59.4±17.7 | 55.2±18.1 |
| Male sex, n (%) | 2136 (80.5) | 420 (83.0) |
| Witnessed by bystander, n (%) | 1228 (46.3) | 226 (44.7) |
| Received bystander CPR, n (%) | 1153 (43.4) | 213 (42.1) |
| Bystander applied AED, n (%) | 254 (9.6) | 72 (14.2) |
| Ambulance response interval, median (IQR), minutes | 5:55 (4:45 – 7:24) | 5:11 (4:10 – 6:16) |
| Initial cardiac rhythm, n (%) | ||
| Shockable† | 917 (34.6) | 167 (33.0) |
| Not Shockable† | 1661 (62.6) | 322 (63.6) |
| Survival to discharge, n (%) | 416 (15.8) | 88 (17.4) |
SD, standard deviation; AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; and IQR, interquartile range
Number missing from total: age (76), sex (14), witnessed by bystander (15), received bystander CPR (2), bystander applied AED (46), arrival interval (54), initial cardiac rhythm (76), survival (28)
Number missing from downtown: age (1), sex (1), witnessed by bystander (4), received bystander CPR (1), bystander applied AED (11), arrival interval (12), initial cardiac rhythm (17), survival (0)
Shockable includes, ventricular fibrillation, ventricular tachycardia and patients listed as shockable. Not shockable includes asystole, pulseless electrical activity, patients listed as not shockable, and patients whose initial rhythm was not obtained as resuscitation was stopped before rhythm analysis by protocol due to obvious signs of death.
Analysis 1: Ranking businesses and municipal locations by spatiotemporal OHCA coverage
Table 2 ranks the 41 businesses and municipal locations in descending order of actual coverage in Toronto. The top-ranked businesses were Tim Hortons (actual coverage=286), Royal Bank of Canada automated teller machine (ATMs) (actual coverage=243) and Subway Restaurants (actual coverage=228). Coffee shops (Tim Hortons, Starbucks, and Second Cup) and ATMs of the five major Canadian banks (Royal Bank of Canada, Bank of Nova Scotia, Canadian Imperial Bank of Commerce, Toronto-Dominion Bank, and Bank of Montreal) occupied eight of the top 10 location types. The top-ranked businesses in coverage efficiency were 7-Eleven (coverage efficiency=1.92), Burger King, (coverage efficiency=1.73), and Second Cup, (coverage efficiency=1.39). The businesses with the largest coverage loss were Wendy’s (coverage loss=78.6%), UPS Stores (coverage loss=67.7%), and Scotiabank Branches (coverage loss=62.9%). The geographical distribution of the top five ranked location types are shown in Supplemental Figures 1 – 6.
Table 2.
Businesses and municipal locations ranked by actual coverage in all of Toronto.
| Rank | Location Type‡ | Location Category | Actual Coverage | Assumed 24/7 Coverage, (Rank) | Number of Facilities, (Rank) | Coverage Efficiency, (Rank) | Coverage Loss, % (Rank) |
|---|---|---|---|---|---|---|---|
| 1 | Tim Hortons | Coffee Shop | 286 | 329 (1) | 312 (2) | 0.92 (14) | 13.1 (14) |
| 2 | RBC ATM | Bank ATM | 243 | 272 (2) | 264 (4) | 0.92 (13) | 10.7 (11) |
| 3 | Subway | Restaurant Chain | 228 | 264 (3) | 281 (3) | 0.81 (19) | 13.6 (15) |
| 4 | Scotiabank ATM | Bank ATM | 216 | 232 (4) | 181 (9) | 1.19 (5) | 6.9 (10) |
| 5 | CIBC ATM | Bank ATM | 198 | 224 (5) | 187 (8) | 1.06 (6) | 11.6 (13) |
| 6 | TD ATM | Bank ATM | 183 | 216 (6) | 178 (10) | 1.03 (8) | 15.3 (18) |
| 7 | Green P Parking | Parking Lot | 177 | 187 (8) | 229 (5) | 0.77 (21) | 5.3 (7) |
| 8 | Starbucks | Coffee Shop | 169 | 208 (7) | 166 (11) | 1.02 (10) | 18.8 (19) |
| 9 | BMO ATM | Bank ATM | 141 | 144 (12) | 142 (13) | 0.99 (11) | 2.1 (6) |
| 10 | Second Cup | Coffee Shop | 111 | 148 (10) | 80 (24) | 1.39 (3) | 25.0 (23) |
| 11 | Shoppers Drug Mart | Pharmacy | 103 | 134 (13) | 132 (14) | 0.78 (20) | 23.1 (22) |
| 12 | McDonald’s | Restaurant Chain | 98 | 105 (17) | 94 (22) | 1.04 (7) | 6.7 (9) |
| 13 | TD Branch | Bank | 94 | 148 (10) | 144 (12) | 0.65 (26) | 36.5 (29) |
| 14 | CIBC Branch | Bank | 91 | 158 (9) | 108 (16) | 0.84 (18) | 42.4 (33) |
| 15 | Pizza Pizza | Restaurant Chain | 86 | 117 (16) | 100 (19) | 0.86 (17) | 26.5 (24) |
| 16 | RBC Branch | Bank | 69 | 125 (15) | 103 (17) | 0.67 (25) | 44.8 (34) |
| 17 | Rexall | Pharmacy | 63 | 91 (19) | 51 (31) | 1.24 (4) | 30.8 (27) |
| 18 | Shell | Gas Station | 55 | 55 (23) | 57 (29) | 0.96 (12) | 0.0 (1) |
| 19 | BMO Branch | Bank | 53 | 98 (18) | 96 (21) | 0.55 (30) | 45.9 (35) |
| 20 | Scotiabank Branch | Bank | 49 | 132 (14) | 98 (20) | 0.50 (31) | 62.9 (39) |
| 21 | Petrocan | Gas Station | 47 | 47 (28) | 74 (26) | 0.64 (28) | 0.0 (1) |
| 22 | 7-Eleven | Convenience Store | 46 | 46 (30) | 24 (38) | 1.92 (1) | 0.0 (1) |
| 23 | Goodlife Fitness | Recreational Facility | 43 | 50 (26) | 42 (32) | 1.02 (9) | 14.0 (17) |
| 24 | Public School | School | 39 | 56 (22) | 584 (1) | 0.07 (41) | 30.4 (26) |
| 24 | LCBO | Liquor/Beer Store | 39 | 59 (21) | 84 (23) | 0.46 (33) | 33.9 (28) |
| 26 | Burger King | Restaurant Chain | 38 | 44 (31) | 22 (40) | 1.73 (2) | 13.6 (15) |
| 26 | Pizza Nova | Restaurant Chain | 38 | 47 (28) | 52 (30) | 0.73 (24) | 19.1 (20) |
| 28 | BeerStore | Liquor/Beer Store | 32 | 51 (25) | 66 (27) | 0.48 (32) | 37.3 (30) |
| 29 | Swiss Chalet | Restaurant Chain | 31 | 52 (24) | 35 (35) | 0.89 (15) | 40.4 (32) |
| 30 | Mac’s | Convenience Store | 28 | 28 (36) | 37 (33) | 0.76 (22) | 0.0 (1) |
| 31 | Library | Library | 25 | 50 (26) | 101 (18) | 0.25 (36) | 50.0 (36) |
| 32 | Harvey’s | Restaurant Chain | 22 | 30 (35) | 25 (37) | 0.88 (16) | 26.7 (25) |
| 32 | Esso | Gas Station | 22 | 22 (38) | 77 (25) | 0.29 (34) | 0.0 (1) |
| 34 | Swimming Pool | Recreational Facility | 18 | 40 (32) | 117 (15) | 0.15 (37) | 55.0 (38) |
| 35 | Metro | Grocery Store | 17 | 18 (40) | 28 (36) | 0.61 (29) | 5.6 (8) |
| 36 | Separate School | School | 16 | 34 (33) | 223 (6) | 0.07 (39) | 52.9 (37) |
| 37 | Private School | School | 15 | 70 (20) | 211 (7) | 0.07 (40) | 78.6 (41) |
| 37 | Wendy’s | Restaurant Chain | 15 | 25 (37) | 20 (41) | 0.75 (23) | 40.0 (31) |
| 37 | Dairy Queen | Restaurant Chain | 15 | 19 (39) | 23 (39) | 0.65 (27) | 21.1 (21) |
| 40 | UPS Store | Retail Store | 10 | 31 (34) | 36 (34) | 0.28 (35) | 67.7 (40) |
| 41 | Canadian Tire | Retail Store | 8 | 9 (41) | 65 (28) | 0.12 (38) | 11.1 (12) |
| Average | 79.9* | 102.8* | 120.7* | 0.91 † | 18.2† |
Coverage Efficiency: the actual coverage divided by the number of facilities; Coverage loss: the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage
Overall average (averaged over all 41 businesses and municipal locations)
Weighted average (over all 41 businesses and municipal locations, weighted by the actual coverage values of each location type)
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Table 3 summarizes the result of the downtown subgroup analysis. The top-ranked businesses by actual coverage were Starbucks (actual coverage=110), Tim Hortons (actual coverage=97), and RBC ATMs (actual coverage=94). The same coffee shop chains and bank ATMs in the top 10 of Table 2, occupied eight of the top 10 rankings in downtown, but in a different order. The top-ranked businesses by coverage efficiency were Burger King (coverage efficiency=4.25), 7-Eleven (coverage efficiency=3.50), and Pizza Nova (coverage efficiency=3.17). The largest coverage losses were experienced by schools: Separate (religious) Schools (coverage loss=100.0%), Public Schools (coverage loss=77.8%), and Private Schools (coverage loss=71.4%).
Table 3.
Businesses and municipal locations ranked by actual coverage in downtown Toronto.
| Downtown Rank | Location Type‡ | Location Category | Actual Coverage | Assumed 24/7 Coverage, (Rank) | Number of Facilities, (Rank) | Coverage Efficiency, (Rank) | Coverage Loss, % (Rank) |
|---|---|---|---|---|---|---|---|
| 1 | Starbucks | Coffee Shop | 110 | 139 (1) | 75 (1) | 1.47 (20) | 20.9 (19) |
| 2 | Tim Hortons | Coffee Shop | 97 | 117 (2) | 73 (2) | 1.33 (22) | 17.1 (15) |
| 3 | RBC ATM | Bank ATM | 94 | 111 (3) | 66 (4) | 1.42 (21) | 15.3 (14) |
| 4 | Scotiabank ATM | Bank ATM | 77 | 84 (6) | 33 (8) | 2.33 (6) | 8.3 (12) |
| 4 | Subway | Restaurant Chain | 77 | 93 (5) | 71 (3) | 1.08 (26) | 17.2 (16) |
| 6 | TD ATM | Bank ATM | 75 | 97 (4) | 39 (6) | 1.92 (11) | 22.7 (20) |
| 7 | Second Cup | Coffee Shop | 67 | 84 (6) | 41 (5) | 1.63 (16) | 20.2 (17) |
| 8 | CIBC ATM | Bank ATM | 64 | 73 (8) | 32 (9) | 2.00 (9) | 12.3 (13) |
| 9 | BMO ATM | Bank ATM | 56 | 58 (10) | 30 (10) | 1.87 (12) | 3.4 (7) |
| 10 | Shoppers Drug Mart | Pharmacy | 53 | 70 (9) | 25 (12) | 2.12 (7) | 24.3 (21) |
| 11 | Green P Parking | Parking Lot | 47 | 50 (11) | 39 (6) | 1.21 (24) | 6.0 (10) |
| 12 | McDonald’s | Restaurant Chain | 39 | 42 (14) | 15 (19) | 2.60 (4) | 7.1 (11) |
| 13 | Rexall | Pharmacy | 27 | 39 (15) | 13 (22) | 2.08 (8) | 30.8 (24) |
| 14 | TD Branch | Bank | 26 | 46 (12) | 22 (13) | 1.18 (25) | 43.5 (29) |
| 15 | CIBC Branch | Bank | 25 | 43 (13) | 17 (16) | 1.47 (19) | 41.9 (28) |
| 16 | Pizza Pizza | Restaurant Chain | 23 | 34 (18) | 14 (21) | 1.64 (15) | 32.4 (25) |
| 16 | Goodlife Fitness | Recreational Facility | 23 | 29 (20) | 13 (22) | 1.77 (13) | 20.7 (18) |
| 18 | 7-Eleven | Convenience Store | 21 | 21 (23) | 6 (31) | 3.50 (2) | 0.0 (1) |
| 19 | Pizza Nova | Restaurant Chain | 19 | 20 (25) | 6 (31) | 3.17 (3) | 5.0 (8) |
| 20 | RBC Branch | Bank | 17 | 38 (16) | 18 (15) | 0.94 (30) | 55.3 (36) |
| 20 | Burger King | Restaurant Chain | 17 | 18 (26) | 4 (33) | 4.25 (1) | 5.6 (9) |
| 20 | LCBO | Liquor/Beer Store | 17 | 23 (21) | 17 (16) | 1.00 (27) | 26.1 (22) |
| 23 | BMO Branch | Bank | 16 | 30 (19) | 16 (18) | 1.00 (27) | 46.7 (31) |
| 24 | Scotiabank Branch | Bank | 13 | 35 (17) | 15 (19) | 0.87 (32) | 62.9 (38) |
| 25 | Swiss Chalet | Restaurant Chain | 11 | 23 (21) | 7 (28) | 1.57 (17) | 52.2 (35) |
| 26 | Harvey’s | Restaurant Chain | 10 | 14 (29) | 4 (33) | 2.50 (5) | 28.6 (23) |
| 26 | BeerStore | Liquor/Beer Store | 10 | 15 (28) | 8 (26) | 1.25 (23) | 33.3 (26) |
| 28 | Metro | Grocery Store | 8 | 8 (33) | 4 (33) | 2.00 (9) | 0.0 (1) |
| 29 | UPS Store | Retail Store | 7 | 18 (26) | 8 (26) | 0.88 (31) | 61.1 (37) |
| 30 | Private School | School | 6 | 21 (23) | 19 (14) | 0.32 (37) | 71.4 (39) |
| 31 | Library | Library | 5 | 9 (31) | 12 (24) | 0.42 (36) | 44.4 (30) |
| 31 | Swimming Pool | Recreational Facility | 5 | 10 (30) | 7 (28) | 0.71 (33) | 50.0 (32) |
| 31 | Dairy Queen | Restaurant Chain | 5 | 8 (33) | 3 (37) | 1.67 (14) | 37.5 (27) |
| 34 | Wendy’s | Restaurant Chain | 3 | 6 (35) | 3 (37) | 1.00 (27) | 50.0 (32) |
| 34 | Mac’s | Convenience Store | 3 | 3 (37) | 2 (40) | 1.50 (18) | 0.0 (1) |
| 36 | Public School | School | 2 | 9 (31) | 29 (11) | 0.07 (41) | 77.8 (41) |
| 36 | Petrocan | Gas Station | 2 | 2 (38) | 3 (37) | 0.67 (34) | 0.0 (1) |
| 38 | Separate School | School | 1 | 4 (36) | 9 (25) | 0.11 (40) | 75.0 (40) |
| 38 | Canadian Tire | Retail Store | 1 | 2 (38) | 7 (28) | 0.14 (39) | 50.0 (32) |
| 38 | Shell | Gas Station | 1 | 1 (40) | 2 (40) | 0.50 (35) | 0.0 (1) |
| 38 | Esso | Gas Station | 1 | 1 (40) | 4 (33) | 0.25 (38) | 0.0 (1) |
| Average | 28.8* | 37.8* | 20.3* | 1.71† | 20.1† |
Coverage Efficiency: the actual coverage divided by the number of facilities; Coverage loss: the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage
Overall average (averaged over all 41 businesses and municipal locations)
Weighted average (over all 41 businesses and municipal locations, weighted by the actual coverage values of each location type)
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Table 4 ranks the 41 businesses and municipal locations with respect to the public OHCAs that were not already covered by a registered AED in Toronto. Coffee shops (Tim Hortons, Starbucks, and Second Cup) and ATMs of the five major Canadian banks remained in the top 10. The rankings for the downtown subgroup can be found in Supplemental Table 8.
Table 4.
Businesses and municipal locations ranked by actual coverage in Toronto based on public OHCAs not already covered by a registered AED.
| Rank | Location Type‡ | Location category | Actual Coverage | Assumed 24/7 Coverage, (Rank) | Number of Facilities, (Rank) | Coverage Efficiency, (Rank) | Coverage Loss, % (Rank) |
|---|---|---|---|---|---|---|---|
| 1 | Tim Hortons | Coffee Shop | 200 | 234 (1) | 312 (2) | 0.64 (18) | 14.5 (16) |
| 2 | RBC ATM | Bank ATM | 172 | 193 (2) | 264 (4) | 0.65 (16) | 10.9 (12) |
| 3 | Subway | Restaurant Chain | 162 | 190 (3) | 281 (3) | 0.58 (21) | 14.7 (17) |
| 4 | Scotiabank ATM | Bank ATM | 136 | 148 (5) | 181 (9) | 0.75 (7) | 8.1 (9) |
| 5 | CIBC ATM | Bank ATM | 134 | 152 (4) | 187 (8) | 0.72 (8) | 11.8 (13) |
| 6 | Green P Parking | Parking Lot | 127 | 135 (7) | 229 (5) | 0.55 (23) | 5.9 (7) |
| 7 | TD ATM | Bank ATM | 121 | 146 (6) | 178 (10) | 0.68 (14) | 17.1 (19) |
| 8 | Starbucks | Coffee Shop | 104 | 125 (8) | 166 (11) | 0.63 (19) | 16.8 (18) |
| 9 | BMO ATM | Bank ATM | 101 | 104 (10) | 142 (13) | 0.71 (9) | 2.9 (6) |
| 10 | Pizza Pizza | Restaurant Chain | 69 | 90 (12) | 100 (19) | 0.69 (12) | 23.3 (23) |
| 11 | Shoppers Drug Mart | Pharmacy | 66 | 83 (16) | 132 (14) | 0.50 (25) | 20.5 (21) |
| 12 | TD Branch | Bank | 62 | 101 (11) | 144 (12) | 0.43 (26) | 38.6 (29) |
| 13 | McDonald’s | Restaurant Chain | 61 | 68 (19) | 94 (22) | 0.65 (17) | 10.3 (11) |
| 14 | Second Cup | Coffee Shop | 61 | 85 (14) | 80 (24) | 0.76 (6) | 28.2 (25) |
| 15 | CIBC Branch | Bank | 60 | 109 (9) | 108 (16) | 0.56 (22) | 45.0 (32) |
| 16 | Rexall | Pharmacy | 50 | 71 (18) | 51 (31) | 0.98 (3) | 29.6 (26) |
| 17 | Petrocan | Gas Station | 45 | 45 (22) | 74 (26) | 0.61 (20) | 0.0 (1) |
| 18 | Shell | Gas Station | 45 | 45 (22) | 57 (29) | 0.79 (5) | 0.0 (1) |
| 19 | RBC Branch | Bank | 44 | 86 (13) | 103 (17) | 0.43 (28) | 48.8 (34) |
| 20 | BMO Branch | Bank | 40 | 76 (17) | 96 (21) | 0.42 (29) | 47.4 (33) |
| 21 | Pizza Nova | Restaurant Chain | 36 | 44 (24) | 52 (30) | 0.69 (11) | 18.2 (20) |
| 22 | Burger King | Restaurant Chain | 34 | 39 (28) | 22 (40) | 1.55 (1) | 12.8 (14) |
| 23 | 7-Eleven | Convenience Store | 32 | 32 (29) | 24 (38) | 1.33 (2) | 0.0 (1) |
| 24 | Scotiabank Branch | Bank | 30 | 84 (15) | 98 (20) | 0.31 (33) | 64.3 (37) |
| 25 | Swiss Chalet | Restaurant Chain | 29 | 47 (21) | 35 (35) | 0.83 (4) | 38.3 (28) |
| 26 | Mac’s | Convenience Store | 26 | 26 (32) | 37 (33) | 0.70 (10) | 0.0 (1) |
| 27 | BeerStore | Liquor/Beer Store | 26 | 42 (26) | 66 (27) | 0.39 (30) | 38.1 (27) |
| 28 | LCBO | Liquor/Beer Store | 26 | 43 (25) | 84 (23) | 0.31 (32) | 39.5 (30) |
| 29 | Public School | School | 24 | 40 (27) | 584 (1) | 0.04 (41) | 40.0 (31) |
| 30 | Goodlife Fitness | Recreational Facility | 22 | 24 (34) | 42 (32) | 0.52 (24) | 8.3 (10) |
| 31 | Esso | Gas Station | 20 | 20 (37) | 77 (25) | 0.26 (34) | 0.0 (1) |
| 32 | Harvey’s | Restaurant Chain | 17 | 23 (35) | 25 (37) | 0.68 (13) | 26.1 (24) |
| 33 | Private School | School | 15 | 58 (20) | 211 (7) | 0.07 (38) | 74.1 (41) |
| 34 | Dairy Queen | Restaurant Chain | 15 | 19 (38) | 23 (39) | 0.65 (15) | 21.1 (22) |
| 35 | Metro | Grocery Store | 12 | 13 (40) | 28 (36) | 0.43 (27) | 7.7 (8) |
| 36 | Separate School | School | 11 | 28 (30) | 223 (6) | 0.05 (40) | 60.7 (36) |
| 37 | Library | Library | 9 | 27 (31) | 101 (18) | 0.09 (37) | 66.7 (39) |
| 38 | UPS Store | Retail Store | 9 | 26 (32) | 36 (34) | 0.25 (35) | 65.4 (38) |
| 39 | Swimming Pool | Recreational Facility | 7 | 23 (35) | 117 (15) | 0.06 (39) | 69.6 (40) |
| 40 | Wendy’s | Restaurant Chain | 7 | 14 (39) | 20 (41) | 0.35 (31) | 50.0 (35) |
| 41 | Canadian Tire | Retail Store | 6 | 7 (41) | 65 (28) | 0.09 (36) | 14.3 (15) |
| Average | 55.4* | 72.3* | 120.7* | 0.63† | 18.8† |
Coverage Efficiency: the actual coverage divided by the number of facilities; Coverage loss: the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage
Overall average (averaged over all 41 businesses and municipal locations)
Weighted average (over all 41 businesses and municipal locations, weighted by the actual coverage values of each location type)
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Analysis 2: Temporal stability of the businesses and municipal location coverage rankings
Table 5 shows the actual coverage for each business and municipal location in Toronto for each year from 2007 to 2015. Table 6 shows the same data for the downtown subgroup. Results in both tables were sorted by average annual actual coverage. Rankings for each individual year were also determined. The ICC values were 0.88 (95% CI, 0.83 to 0.93) for Toronto overall and 0.79 (95% CI, 0.71 to 0.86) for downtown Toronto, indicating high stability of the coverage values over time.
Table 5.
Actual coverage of the 41 businesses and government locations ranked by average actual coverage in all of Toronto per year from 2007 – 2015.
| Rank | Location Type* | Number of Facilities | Actual Coverage, (Ranking) | Annual Actual Coverage mean ± SD | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | ||||
| 1 | Tim Hortons | 312 | 33 (3) | 36 (2) | 26 (1) | 30 (1) | 28 (1) | 35 (1) | 19 (7) | 35 (1) | 44 (1) | 31.8 ± 7.1 |
| 2 | RBC ATM | 264 | 35 (1) | 27 (3) | 25 (2) | 29 (2) | 19 (4) | 27 (2) | 25 (1) | 31 (2) | 25 (6) | 27.0 ± 4.5 |
| 3 | Subway | 281 | 29 (5) | 37 (1) | 24 (3) | 20 (5) | 12 (9) | 24 (3) | 23 (4) | 31 (2) | 28 (4) | 25.3 ± 7.1 |
| 4 | Scotiabank ATM | 181 | 34 (2) | 22 (5) | 21 (4) | 21 (3) | 19 (4) | 16 (7) | 25 (1) | 28 (5) | 30 (3) | 24.0 ± 5.7 |
| 5 | CIBC ATM | 187 | 28 (6) | 15 (8) | 17 (7) | 21 (3) | 19 (4) | 18 (5) | 19 (7) | 30 (4) | 31 (2) | 22.0 ± 6.0 |
| 6 | TD ATM | 178 | 23 (7) | 18 (7) | 20 (5) | 16 (6) | 21 (3) | 21 (4) | 20 (6) | 18 (7) | 26 (5) | 20.3 ± 3.0 |
| 7 | Green P Parking | 229 | 30 (4) | 21 (6) | 16 (8) | 15 (8) | 19 (4) | 17 (6) | 23 (4) | 16 (8) | 20 (7) | 19.7 ± 4.7 |
| 8 | Starbucks | 166 | 23 (7) | 23 (4) | 19 (6) | 14 (9) | 19 (4) | 13 (9) | 19 (7) | 21 (6) | 18 (8) | 18.8 ± 3.5 |
| 9 | BMO ATM | 142 | 19 (9) | 13 (10) | 14 (9) | 10 (10) | 22 (2) | 7 (14) | 24 (3) | 14 (9) | 18 (8) | 15.7 ± 5.5 |
| 10 | Second Cup | 80 | 16 (10) | 15 (8) | 9 (14) | 16 (6) | 9 (13) | 9 (11) | 12 (10) | 11 (14) | 14 (11) | 12.3 ± 3.0 |
| 11 | Shoppers Drug Mart | 132 | 10 (15) | 9 (13) | 10 (13) | 9 (12) | 8 (16) | 15 (8) | 11 (15) | 13 (11) | 18 (8) | 11.4 ± 3.3 |
| 12 | McDonald’s | 94 | 12 (12) | 12 (11) | 11 (12) | 7 (15) | 11 (10) | 6 (17) | 12 (10) | 13 (11) | 14 (11) | 10.9 ± 2.7 |
| 13 | TD Branch | 144 | 15 (11) | 6 (17) | 13 (11) | 9 (12) | 9 (13) | 11 (10) | 12 (10) | 8 (17) | 11 (14) | 10.4 ± 2.7 |
| 14 | CIBC Branch | 108 | 11 (13) | 6 (17) | 8 (15) | 10 (10) | 9 (13) | 9 (11) | 12 (10) | 14 (9) | 12 (13) | 10.1 ± 2.4 |
| 15 | Pizza Pizza | 100 | 9 (17) | 12 (11) | 14 (9) | 7 (15) | 11 (10) | 7 (14) | 8 (17) | 7 (18) | 11 (14) | 9.6 ± 2.6 |
| 16 | RBC Branch | 103 | 9 (17) | 8 (14) | 7 (17) | 9 (12) | 6 (18) | 5 (19) | 10 (16) | 12 (13) | 3 (29) | 7.7 ± 2.7 |
| 17 | Rexall | 51 | 11 (13) | 5 (20) | 7 (17) | 6 (17) | 6 (18) | 6 (17) | 6 (20) | 6 (20) | 10 (17) | 7.0 ± 2.1 |
| 18 | Shell | 57 | 6 (20) | 5 (20) | 7 (17) | 6 (17) | 5 (20) | 4 (23) | 6 (20) | 11 (14) | 5 (28) | 6.1 ± 2.0 |
| 19 | BMO Branch | 96 | 5 (21) | 5 (20) | 3 (27) | 5 (19) | 11 (10) | 1 (35) | 12 (10) | 4 (25) | 7 (21) | 5.9 ± 3.6 |
| 20 | Scotiabank Branch | 98 | 10 (15) | 8 (14) | 4 (23) | 3 (26) | 7 (17) | 2 (29) | 2 (31) | 7 (18) | 6 (26) | 5.4 ± 2.8 |
| 21 | Petrocan | 74 | 5 (21) | 8 (14) | 6 (20) | 3 (26) | 2 (31) | 7 (14) | 4 (25) | 9 (16) | 3 (29) | 5.2 ± 2.4 |
| 22 | 7-Eleven | 24 | 4 (25) | 5 (20) | 4 (23) | 4 (22) | 3 (25) | 5 (19) | 7 (18) | 3 (30) | 11 (14) | 5.1 ± 2.5 |
| 23 | Goodlife Fitness | 42 | 8 (19) | 5 (20) | 5 (21) | 2 (30) | 4 (22) | 2 (29) | 6 (20) | 4 (25) | 7 (21) | 4.8 ± 2.0 |
| 24 | Public School | 584 | 5 (21) | 2 (34) | 4 (23) | 3 (26) | 3 (25) | 2 (29) | 7 (18) | 5 (21) | 8 (18) | 4.3 ± 2.1 |
| 24 | LCBO | 84 | 5 (21) | 3 (28) | 3 (27) | 3 (26) | 3 (25) | 8 (13) | 2 (31) | 5 (21) | 7 (21) | 4.3 ± 2.1 |
| 26 | Burger King | 22 | 3 (27) | 3 (28) | 8 (15) | 2 (30) | 3 (25) | 4 (23) | 4 (25) | 4 (25) | 7 (21) | 4.2 ± 2.0 |
| 26 | Pizza Nova | 52 | 4 (25) | 6 (17) | 4 (23) | 5 (19) | 1 (34) | 4 (23) | 4 (25) | 2 (34) | 8 (18) | 4.2 ± 2.0 |
| 28 | BeerStore | 66 | 1 (34) | 4 (25) | 1 (38) | 1 (34) | 4 (22) | 5 (19) | 4 (25) | 5 (21) | 7 (21) | 3.6 ± 2.1 |
| 29 | Swiss Chalet | 35 | 2 (31) | 3 (28) | 3 (27) | 4 (22) | 4 (22) | 5 (19) | 6 (20) | 2 (34) | 2 (35) | 3.4 ± 1.4 |
| 30 | Mac’s | 37 | 1 (34) | 4 (25) | 5 (21) | 4 (22) | 3 (25) | 0 (39) | 1 (36) | 2 (34) | 8 (18) | 3.1 ± 2.5 |
| 31 | Library | 101 | 3 (27) | 3 (28) | 0 (39) | 4 (22) | 0 (39) | 1 (35) | 4 (25) | 4 (25) | 6 (26) | 2.8 ± 2.0 |
| 32 | Harvey’s | 25 | 0 (37) | 0 (41) | 3 (27) | 5 (19) | 3 (25) | 3 (26) | 0 (41) | 5 (21) | 3 (29) | 2.4 ± 2.0 |
| 32 | Esso | 77 | 3 (27) | 2 (34) | 2 (35) | 2 (30) | 1 (34) | 3 (26) | 6 (20) | 1 (37) | 2 (35) | 2.4 ± 1.5 |
| 34 | Swimming Pool | 117 | 0 (37) | 3 (28) | 2 (35) | 0 (37) | 5 (20) | 3 (26) | 1 (36) | 4 (25) | 0 (40) | 2.0 ± 1.9 |
| 35 | Metro | 28 | 3 (27) | 4 (25) | 3 (27) | 0 (37) | 1 (34) | 1 (35) | 1 (36) | 1 (37) | 3 (29) | 1.9 ± 1.4 |
| 36 | Separate School | 223 | 0 (37) | 2 (34) | 3 (27) | 1 (34) | 2 (31) | 2 (29) | 1 (36) | 1 (37) | 3 (29) | 1.8 ± 1.3 |
| 37 | Private School | 211 | 2 (31) | 1 (37) | 0 (39) | 2 (30) | 1 (34) | 2 (29) | 2 (31) | 0 (41) | 3 (29) | 1.7 ± 1.0 |
| 37 | Wendy’s | 20 | 0 (37) | 1 (37) | 3 (27) | 1 (34) | 1 (34) | 2 (29) | 4 (25) | 3 (30) | 0 (40) | 1.7 ± 1.4 |
| 37 | Dairy Queen | 23 | 0 (37) | 3 (28) | 3 (27) | 0 (37) | 2 (31) | 0 (39) | 2 (31) | 3 (30) | 2 (35) | 1.7 ± 1.3 |
| 40 | UPS Store | 36 | 1 (34) | 1 (37) | 2 (35) | 0 (37) | 0 (39) | 1 (35) | 2 (31) | 1 (37) | 2 (35) | 1.1 ± 0.8 |
| 41 | Canadian Tire | 65 | 2 (31) | 1 (37) | 0 (39) | 0 (37) | 0 (39) | 0 (39) | 1 (36) | 3 (30) | 1 (39) | 0.9 ± 1.1 |
The ICC value for temporal variation in coverage is 0.88 (95%CI, 0.83 to 0.93).
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Table 6.
Actual coverage of the 41 businesses and government locations ranked by average actual coverage in downtown Toronto per year from 2007 – 2015.
| Downtown Rank | Downtown Location Type* | Number of Facilities | Actual Coverage, (Ranking) | Average Actual Coverage per year ± SD | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | ||||
| 1 | Starbucks | 75 | 11 (4) | 16 (3) | 13 (2) | 8 (1) | 14 (1) | 13 (1) | 10 (2) | 10 (3) | 15 (3) | 12.2 ± 2.6 |
| 2 | Tim Hortons | 73 | 11 (4) | 18 (1) | 8 (6) | 8 (1) | 6 (4) | 10 (3) | 12 (1) | 8 (6) | 16 (2) | 10.8 ± 4.0 |
| 3 | RBC ATM | 66 | 12 (3) | 18 (1) | 10 (3) | 4 (6) | 6 (4) | 8 (5) | 7 (4) | 11 (1) | 18 (1) | 10.4 ± 5.0 |
| 4 | Scotiabank ATM | 33 | 15 (1) | 12 (5) | 9 (4) | 3 (13) | 8 (2) | 8 (5) | 7 (4) | 6 (8) | 9 (7) | 8.6 ± 3.4 |
| 4 | Subway | 71 | 13 (2) | 10 (6) | 7 (7) | 6 (4) | 4 (8) | 10 (3) | 6 (9) | 10 (3) | 11 (4) | 8.6 ± 2.9 |
| 6 | TD ATM | 39 | 4 (12) | 8 (8) | 14 (1) | 4 (6) | 8 (2) | 12 (2) | 7 (4) | 11 (1) | 7 (11) | 8.3 ± 3.4 |
| 7 | Second Cup | 41 | 8 (7) | 13 (4) | 6 (10) | 5 (5) | 5 (6) | 3 (12) | 10 (2) | 7 (7) | 10 (5) | 7.4 ± 3.1 |
| 8 | CIBC ATM | 32 | 10 (6) | 7 (9) | 7 (7) | 8 (1) | 3 (11) | 6 (8) | 4 (13) | 10 (3) | 9 (7) | 7.1 ± 2.5 |
| 9 | BMO ATM | 30 | 5 (8) | 9 (7) | 9 (4) | 4 (6) | 4 (8) | 4 (11) | 7 (4) | 6 (8) | 8 (10) | 6.2 ± 2.1 |
| 10 | Shoppers Drug Mart | 25 | 5 (8) | 5 (12) | 6 (10) | 4 (6) | 5 (6) | 5 (10) | 7 (4) | 6 (8) | 10 (5) | 5.9 ± 1.8 |
| 11 | Green P Parking | 39 | 5 (8) | 6 (11) | 7 (7) | 3 (13) | 0 (27) | 7 (7) | 5 (10) | 5 (11) | 9 (7) | 5.2 ± 2.6 |
| 12 | McDonald’s | 15 | 4 (12) | 7 (9) | 6 (10) | 1 (21) | 3 (11) | 3 (12) | 5 (10) | 4 (13) | 6 (12) | 4.3 ± 1.9 |
| 13 | Rexall | 13 | 3 (14) | 4 (14) | 2 (15) | 4 (6) | 3 (11) | 3 (12) | 3 (14) | 3 (17) | 2 (18) | 3.0 ± 0.7 |
| 14 | TD Branch | 22 | 3 (14) | 2 (19) | 5 (13) | 4 (6) | 2 (14) | 3 (12) | 2 (18) | 4 (13) | 1 (25) | 2.9 ± 1.3 |
| 15 | CIBC Branch | 17 | 3 (14) | 3 (15) | 1 (21) | 4 (6) | 2 (14) | 2 (17) | 2 (18) | 5 (11) | 3 (16) | 2.8 ± 1.2 |
| 16 | Pizza Pizza | 14 | 2 (19) | 2 (19) | 3 (14) | 3 (13) | 1 (18) | 3 (12) | 5 (10) | 1 (24) | 3 (16) | 2.6 ± 1.2 |
| 16 | Goodlife Fitness | 13 | 2 (19) | 1 (23) | 2 (15) | 3 (13) | 4 (8) | 6 (8) | 0 (31) | 0 (29) | 5 (13) | 2.6 ± 2.1 |
| 18 | 7-Eleven | 6 | 3 (14) | 3 (15) | 2 (15) | 1 (21) | 1 (18) | 2 (17) | 2 (18) | 2 (20) | 5 (13) | 2.3 ± 1.2 |
| 19 | Pizza Nova | 6 | 5 (8) | 1 (23) | 1 (21) | 2 (18) | 1 (18) | 2 (17) | 3 (14) | 2 (20) | 2 (18) | 2.1 ± 1.3 |
| 20 | RBC Branch | 18 | 1 (24) | 1 (23) | 0 (32) | 3 (13) | 1 (18) | 2 (17) | 2 (18) | 2 (20) | 5 (13) | 1.9 ± 1.5 |
| 20 | Burger King | 4 | 2 (19) | 3 (15) | 1 (21) | 1 (21) | 2 (14) | 1 (25) | 2 (18) | 3 (17) | 2 (18) | 1.9 ± 0.8 |
| 20 | LCBO | 17 | 3 (14) | 1 (23) | 2 (15) | 2 (18) | 1 (18) | 2 (17) | 0 (31) | 4 (13) | 2 (18) | 1.9 ± 1.2 |
| 23 | BMO Branch | 16 | 1 (24) | 3 (15) | 2 (15) | 1 (21) | 0 (27) | 2 (17) | 3 (14) | 3 (17) | 1 (25) | 1.8 ± 1.1 |
| 24 | Scotiabank Branch | 15 | 2 (19) | 5 (12) | 0 (32) | 0 (27) | 2 (14) | 2 (17) | 2 (18) | 0 (29) | 0 (35) | 1.4 ± 1.7 |
| 25 | Swiss Chalet | 7 | 2 (19) | 0 (34) | 1 (21) | 0 (27) | 1 (18) | 1 (25) | 3 (14) | 1 (24) | 2 (18) | 1.2 ± 1.0 |
| 26 | Harvey’s | 4 | 0 (32) | 1 (23) | 1 (21) | 0 (27) | 1 (18) | 1 (25) | 1 (25) | 4 (13) | 1 (25) | 1.1 ± 1.2 |
| 26 | BeerStore | 8 | 0 (32) | 1 (23) | 1 (21) | 2 (18) | 0 (27) | 1 (25) | 1 (25) | 2 (20) | 2 (18) | 1.1 ± 0.8 |
| 28 | Metro | 4 | 1 (24) | 1 (23) | 1 (21) | 0 (27) | 0 (27) | 2 (17) | 1 (25) | 1 (24) | 1 (25) | 0.9 ± 0.6 |
| 29 | UPS Store | 8 | 0 (32) | 0 (34) | 2 (15) | 1 (21) | 1 (18) | 0 (32) | 2 (18) | 0 (29) | 1 (25) | 0.8 ± 0.8 |
| 30 | Private School | 19 | 1 (24) | 0 (34) | 1 (21) | 1 (21) | 0 (27) | 0 (32) | 0 (31) | 1 (24) | 2 (18) | 0.7 ± 0.7 |
| 31 | Library | 12 | 1 (24) | 1 (23) | 1 (21) | 0 (27) | 0 (27) | 0 (32) | 1 (25) | 0 (29) | 1 (25) | 0.6 ± 0.5 |
| 31 | Swimming Pool | 7 | 0 (32) | 2 (19) | 1 (21) | 0 (27) | 0 (27) | 1 (25) | 0 (31) | 0 (29) | 1 (25) | 0.6 ± 0.7 |
| 31 | Dairy Queen | 3 | 1 (24) | 2 (19) | 0 (32) | 0 (27) | 0 (27) | 0 (32) | 0 (31) | 1 (24) | 1 (25) | 0.6 ± 0.7 |
| 34 | Wendy’s | 3 | 0 (32) | 1 (23) | 0 (32) | 0 (27) | 0 (27) | 0 (32) | 1 (25) | 0 (29) | 1 (25) | 0.3 ± 0.5 |
| 34 | Mac’s | 2 | 0 (32) | 0 (34) | 0 (32) | 0 (27) | 0 (27) | 1 (25) | 1 (25) | 0 (29) | 1 (25) | 0.3 ± 0.5 |
| 36 | Public School | 29 | 1 (24) | 0 (34) | 1 (21) | 0 (27) | 0 (27) | 0 (32) | 0 (31) | 0 (29) | 0 (35) | 0.2 ± 0.4 |
| 36 | Petrocan | 3 | 1 (24) | 1 (23) | 0 (32) | 0 (27) | 0 (27) | 0 (32) | 0 (31) | 0 (29) | 0 (35) | 0.2 ± 0.4 |
| 38 | Separate School | 9 | 0 (32) | 1 (23) | 0 (32) | 0 (27) | 0 (27) | 0 (32) | 0 (31) | 0 (29) | 0 (35) | 0.1 ± 0.3 |
| 38 | Canadian Tire | 7 | 0 (32) | 0 (34) | 0 (32) | 0 (27) | 1 (18) | 0 (32) | 0 (31) | 0 (29) | 0 (35) | 0.1 ± 0.3 |
| 38 | Shell | 2 | 0 (32) | 0 (34) | 0 (32) | 0 (27) | 0 (27) | 0 (32) | 0 (31) | 0 (29) | 0 (35) | 0.1 ± 0.3 |
| 38 | Esso | 4 | 0 (32) | 0 (34) | 0 (32) | 0 (27) | 0 (27) | 1 (25) | 0 (31) | 0 (29) | 0 (35) | 0.1 ± 0.3 |
The ICC value for temporal variation in coverage is 0.79 (95% CI, 0.71 to 0.86).
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Analysis 3: Ranking broad location categories by spatiotemporal OHCA coverage
Tables 7 and 8 summarize the rankings of the broad location categories for Toronto and downtown Toronto, respectively. They are ranked in descending order of actual coverage. Reflecting the individual business and municipal location rankings, the bank ATM category and coffee shop category were both ranked highly. The bank ATM category was ranked first in both Toronto and downtown Toronto. The coffee shop category was ranked 3rd and 2nd in the two areas, respectively. Restaurant chains ranked highly as well, but consisted of the most number of individual businesses (n = 9) than any other category (see Supplemental Table 1 for the taxonomy of individual businesses and municipal locations in broad location categories). Convenience stores had the highest coverage efficiency in both Toronto (coverage efficiency=1.21) and downtown (coverage efficiency=3.00). The largest coverage losses were experienced by schools in both Toronto (coverage loss=56.3%), and downtown Toronto (coverage loss=73.5%).
Table 7.
Broad location categories ranked by actual coverage in Toronto.
| Rank | Location Category‡ | Actual Coverage | Assumed 24/7 Coverage, (Rank) | Number of Facilities, (Rank) | Coverage Efficiency, (Rank) | Coverage Loss, % (Rank) |
|---|---|---|---|---|---|---|
| 1 | Bank ATM | 640 | 697 (1) | 952 (2) | 0.67 (6) | 8.2 (5) |
| 2 | Restaurant Chain | 444 | 523 (2) | 652 (3) | 0.68 (5) | 15.1 (7) |
| 3 | Coffee Shop | 443 | 518 (3) | 558 (4) | 0.79 (3) | 14.5 (6) |
| 4 | Bank | 260 | 470 (4) | 549 (5) | 0.47 (9) | 44.7 (11) |
| 5 | Parking Lot | 177 | 187 (6) | 229 (6) | 0.77 (4) | 5.3 (3) |
| 6 | Pharmacy | 163 | 222 (5) | 183 (8) | 0.89 (2) | 26.6 (8) |
| 7 | Gas Station | 117 | 117 (8) | 208 (7) | 0.56 (8) | 0.0 (1) |
| 8 | Convenience Store | 74 | 74 (11) | 61 (13) | 1.21 (1) | 0.0 (1) |
| 9 | Liquor/Beer Store | 69 | 108 (9) | 150 (10) | 0.46 (10) | 36.1 (10) |
| 10 | School | 69 | 158 (7) | 1018 (1) | 0.07 (14) | 56.3 (14) |
| 11 | Recreational Facility | 61 | 88 (10) | 159 (9) | 0.38 (11) | 30.7 (9) |
| 12 | Library | 25 | 50 (12) | 101 (11) | 0.25 (12) | 50.0 (12) |
| 13 | Retail Store | 18 | 40 (13) | 101 (11) | 0.18 (13) | 55.0 (13) |
| 14 | Grocery Store | 17 | 18 (14) | 28 (14) | 0.61 (7) | 5.6 (4) |
| Average | 184.1* | 233.6* | 340.1* | 0.67† | 17.8† |
Coverage Efficiency: the actual coverage divided by the number of facilities; Coverage loss: the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage
Overall average (averaged over all 14 broad location categories)
Weighted average (over all 14 broad location categories, weighted by the actual coverage values of each location category)
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
Table 8.
Broad location categories ranked by actual coverage in downtown Toronto.
| Downtown Rank | Location Category‡ | Actual Coverage | Assumed 24/7 Coverage, (Rank) | Number of Facilities, (Rank) | Coverage Efficiency, (Rank) | Coverage Loss, % (Rank) |
|---|---|---|---|---|---|---|
| 1 | Bank ATM | 218 | 242 (1) | 200 (1) | 1.09 (7) | 9.9 (5) |
| 2 | Coffee Shop | 186 | 224 (2) | 189 (2) | 0.98 (9) | 17.0 (6) |
| 3 | Restaurant Chain | 148 | 182 (3) | 127 (3) | 1.17 (6) | 18.7 (7) |
| 4 | Pharmacy | 78 | 107 (5) | 38 (7) | 2.05 (2) | 27.1 (9) |
| 5 | Bank | 74 | 134 (4) | 88 (4) | 0.84 (10) | 44.8 (12) |
| 6 | Parking Lot | 47 | 50 (6) | 39 (6) | 1.21 (5) | 6.0 (4) |
| 7 | Recreational Facility | 28 | 38 (7) | 20 (9) | 1.40 (4) | 26.3 (8) |
| 8 | Liquor/Beer Store | 25 | 36 (8) | 25 (8) | 1.00 (8) | 30.6 (10) |
| 9 | Convenience Store | 24 | 24 (10) | 8 (13) | 3.00 (1) | 0.0 (1) |
| 10 | School | 9 | 34 (9) | 57 (5) | 0.16 (14) | 73.5 (14) |
| 11 | Grocery Store | 8 | 8 (13) | 4 (14) | 2.00 (3) | 0.0 (1) |
| 12 | Retail Store | 8 | 20 (11) | 15 (10) | 0.53 (11) | 60.0 (13) |
| 13 | Library | 5 | 9 (12) | 12 (11) | 0.42 (13) | 44.4 (11) |
| 14 | Gas Station | 4 | 4 (14) | 9 (12) | 0.44 (12) | 0.0 (1) |
| Average | 61.6* | 79.4* | 59.4* | 1.20† | 19.3† |
Coverage Efficiency: the actual coverage divided by the number of facilities; Coverage loss: the assumed 24/7 coverage minus actual coverage all divided by assumed 24/7 coverage
Overall average (averaged over all 14 broad location categories)
Weighted average (over all 14 broad location categories, weighted by the actual coverage values of each location category)
ATM, Automated Teller Machine; BMO, Bank of Montreal; CIBC, Canadian Imperial Bank of Commerce; LCBO, Liquor Control Board of Ontario; RBC, Royal Bank of Canada; Separate School, religious schools (students from a religious group); Scotiabank, Bank of Nova Scotia; TD, Toronto-Dominion Bank.
The ATM locations consist of stand-alone ATMS and ATMs located in their respective bank branches.
The broad location category rankings with respect to the public OHCAs that are not already covered by a registered AED in Toronto can be found in Supplemental Tables 9 and 10. In this case, bank ATMs, coffee shops, and restaurant chains retained their top three rankings in both Toronto, and downtown Toronto.
Discussion
In this study, we determined novel rankings of specific businesses and municipal locations by spatiotemporal OHCA coverage in Toronto, Canada. We found that eight of the top ten location types in both Toronto overall and downtown Toronto were coffee shops and bank ATMs. Furthermore, the rankings were fairly stable over time. For example, most of the top ten location types in actual coverage remained in the top ten for every year from 2007 to 2015. When the individual businesses and municipal locations were consolidated into broad location categories, coffee shops and bank ATMs remained among the highest ranking location categories in spatiotemporal coverage.
The analysis presented in Table 4 sheds light on the potential impact of implementing a private-public AED partnership in a realistic case where there are existing AEDs deployed. We found that ATMs and coffee shops retained their high ranking even after removing OHCAs already covered by existing AEDs. However, these findings are specific to Toronto and are not meant to be generalized to other settings as each city’s existing public AED network is unique.
Besides providing high coverage for spatiotemporal OHCA risk, bank ATMs and coffee shops may be promising locations for AED deployment for additional reasons. For example, ATMs offer additional security (e.g., video cameras), weather protection (e.g., electricity to heat an AED cabinet), increased accessibility (many are available 24/7 and located outdoors), and broad recognition (most people would know where to find an ATM locally and they are easily recognized, even in foreign cities). Like ATMs, coffee shops tend to be geographically widespread, located in more populated areas with operating hours that extend past general working hours, and have strong brand recognition. Our results also show that ATMs and coffee shops have high coverage efficiency, which means that partnerships with these businesses may make more effective use of limited resources for AED deployment. Furthermore, our stability results suggest that ATMs and coffee shops, like the other high potential locations for AED deployment, will remain good choices in the future, which is an important consideration since AEDs are typically not moved after they are deployed. Relocating AEDs also has the negative side effect of disrupting any public association between AEDs and specific locations. We believe the combinations of characteristics described make these businesses strong candidates for potential PAD program partnerships.
Our stability results are consistent with a previous study that demonstrated temporal stability of OHCA incidence in Toronto.32 In fact, our ICC values were even higher than found in the previous study, which examined OHCA incidence in all 140 neighborhoods in Toronto. These neighborhoods aggregate the risk of many different businesses and communities into one number. We believe that examining more granular location categories such as specific businesses and municipal locations results in more consistent measurements from year to year. Our analysis of risk in specific locations further supports the notion of committing resources to high risk areas to help improve survival outcomes, as high-risk areas will remain high-risk long term.
Rankings based on the broad location categories (Tables 7 and 8) are important for generalizability of our findings beyond Toronto, Canada. Our findings are in line with previous studies conducted in Denmark and Canada that examined the spatial-only OHCA risk at broad location categories. They identified large businesses (businesses with at least 150 employees), supermarkets, offices, and retail stores as locations with high absolute OHCA risk.13, 15 However, it is also important to examine specific businesses and municipal locations since OHCA risk can vary significantly within a broad location category. For example, the restaurant chain category is ranked second in spatiotemporal coverage among the broad location categories, but the nine individual restaurants that make up the category rank between 3rd and 37th out of 41 total businesses/municipal locations, with an average rank of 24. Furthermore, to achieve the coverage indicated by a broad location category would potentially require working with many different (often competing) businesses, each with their own decision making processes. Overall, by examining specific location types we can obtain more accurate estimates of spatiotemporal cardiac arrest risk to help direct policy decisions and public-private partnerships to improve future PAD placement.
Ranking locations by actual coverage takes into account temporal accessibility, which has been shown to significantly impact the potential availability of AEDs in an emergency situation.21, 22 If AEDs are placed inside a business, then actual coverage is the appropriate metric to consider. However, if AEDs can be made available 24 hours a day (e.g., in a cabinet outside the building), then the relevant coverage metric becomes assumed 24/7 coverage. The coverage loss metric, which measures the relative difference between assumed 24/7 coverage and actual coverage, quantifies the additional value of having around the clock access to AEDs. For example, Wendy’s is ranked first in terms of coverage loss, which means that 24/7 accessible AEDs would be much more valuable than AEDs placed inside the restaurant, which would be unavailable when the restaurant is closed.
Coverage efficiency, which measures the actual coverage per facility, is an indicator of how much coverage can be provided by an AED placed at a single location. Businesses with high coverage efficiency tended to have fewer total facilities compared to the average. For almost all location types analyzed, coverage efficiency was higher in downtown Toronto, most likely due to increased population density. While coverage efficiency does not equal cost-effectiveness, it can be used to gauge the value of an AED placed in a specific business or municipal location. We hypothesize that placing AEDs in businesses with high coverage efficiency will be more cost-effective than placing AEDs in low coverage efficiency locations. AED placement strategies based on OHCA risk and optimization have been found to be cost-effective.13, 30
These rankings may be helpful to municipalities, public safety agencies, and policy makers involved in public access defibrillation programs, especially where public-private partnerships for AEDs are being considered. Business-based partnerships for AED deployment have several advantages beyond coverage of OHCA risk. For example, these organizations may provide financial support to buy AEDs and marketing support to improve PAD program awareness in connection with their brand. By deploying AEDs in all locations of well-known and highly visible franchises (e.g., well-known coffee shop chains) and undertaking a well-planned public awareness campaign, communities may be able to increase access to and awareness of AEDs. Large businesses with a national presence may also be able to provide the necessary financial resources, infrastructure, and leadership to support a nationwide PAD program partnership.
There are some previous examples of public-private partnerships in AED deployment. Recently, over 60 public AEDs were installed in outdoor cabinets integrated with advertisement boards in Vienna in partnership with a local advertising company.33, 34 Across Japan, AEDs have also been installed in vending machines as well as advertisement boards.35 Both partnerships were made possible through creative financing, including contributions from advertising and vending machine revenues, the AED distributor, and the municipalities. In addition to the possibility of broad geographical coverage, like that provided by advertisement boards and vending machines, businesses and municipal locations have the additional potential to improve response by having trained employees act as responders on-site. Our rankings examined the total coverage of all facilities of a single business, modeling the potential coverage of universal AED deployment, i.e., placing AEDs all locations of the business. Universal deployment can give bystanders confidence that they will find an AED at any location of that business. However, not all locations of the same business may have the same risk, and resource limitations may outweigh the benefits of universal deployment. In that case, optimizing AED deployment to a subset of the locations may provide maximum benefit within a constrained budget.20, 22, 30
Coverage, risk, and AED accessibility are only a few of the factors that need to be considered when designing a PAD program. Additional factors such as security, signage, EMS integration, registration with local EMS dispatch, existing AEDs placements, and the presence of trained responders are key considerations as well. For example, an area with good coverage from existing AEDs may only receive marginal benefit from additional AED deployment in that area. More benefit might be realized from by expanding the “coverage radius” of existing AEDs in that area, through improved signage, accessibility, or employee training. 36
Limitations
As a measure of temporal availability, we used the hours of operation associated with each facility. These hours of operation were collected at one point in the year, but we note that hours may fluctuate seasonally. Hours of operations used in the analysis do no account for holiday closures.
In our analysis of ranking stability we assumed that all facilities of each business or municipal location were present every year, based on presence at the time of data collection. Thus, depending on whether there were more or fewer locations of a certain business in the past, our coverage values could be underestimated or overestimated, respectively.
We used 20 businesses as a cutoff so as to focus on large, recognizable businesses in this study. These large businesses would make the most sense for public-private partnerships from the perspective of visibility. However, due to this cut off it is possible we did not include certain businesses and municipal locations in the study that could be beneficial towards improving OHCA coverage and developing AED programs.
This analysis was conducted with cardiac arrest and franchise data from Toronto. The businesses we examined were specific to Toronto and may not exist in other cities. It is also important to note that public OHCAs, the focus of this paper, comprise a minority of all OHCAs.
Conclusion
We determined novel rankings of specific businesses and municipal locations in terms of spatiotemporal OHCA coverage in Toronto, Canada and found they exhibit high temporal stability, suggesting that locations that maximize coverage would continue to do so over time. Overall, we found coffee shops and bank ATMs ranked highly. Our rankings can help policy makers and funders to identify and prioritize potential partnerships for AED deployment, which can increase the distribution and awareness of AED locations and ultimately help improve OHCA survival.
Supplementary Material
Clinical Perspective.
What is new?
We present novel rankings of specific businesses and municipal locations in Toronto, Canada based on spatiotemporal OHCA coverage, the number of OHCAs that occur within 100 m of a given location when that location is open based on hours of operation, and related metrics.
We found that coffee shops (Tim Hortons, Starbucks, and Second Cup) and automated teller machines from the five major banks provided the highest OHCA coverage and their rankings were stable over time.
What are the clinical implications?
Health organizations and policy makers focused on developing public access defibrillator programs can use our rankings to identify businesses and municipal locations to develop partnerships for AED deployment and PAD programs.
These private-public partnerships with businesses and municipal locations may provide benefits such as financial support, increased AED awareness and accessibility, and reduce the barriers to AED deployment and distribution.
Acknowledgments
The authors acknowledge Cathy Zhan for help with gathering demographic data associated with the cardiac arrests. The authors would like to thank the Rescu Epistry investigators and all emergency medical service operators, providers and medical directors as well as the in-hospital staff in the SPARC network hospitals working together in the front line of emergency patient care for their continued commitment contributions to high quality care and primary data collection in resuscitation research at Rescu, Li Ka Shing Knowledge Institute.
Funding/Support
Funding Sources: This project was funded by a ZOLL Foundation grant. The Resuscitation Outcomes Consortium Epistry study is supported by a cooperative agreement (5U01 HL077863) with the National Heart, Lung, and Blood Institute in partnership with the National Institute of Neurological Disorders and Stroke, Canadian Institutes of Health Research–Institute of Circulatory and Respiratory Health, Defense Research and Development Canada, Heart and Stroke Foundation of Canada, and American Heart Association. Rescu Epistry is funded by a centre grant from the Laerdal Foundation, and knowledge translation collaborative grants and operating grants from Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada.
Footnotes
Conflict of Interest Disclosures
Dr. Brooks has reported receiving a CIHR grant to study PulsePoint, which is a mobile device application to crowdsource basic life support, including public access defibrillation, for victims of OHCA. Dr. Morrison has reported having peer reviewed grant funding for cardiac arrest research from the National Institute of Health, Canadian Institute of Health Research, Heart and Stroke Foundation of Canada and I receive salary support from the Robert and Dorothy Pitts endowed chair in Emergency Medicine and Acute Care at Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto. Prof. Chan has reported receiving a grant from the ZOLL Foundation.
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