Questions/Answers

Early cardiopulmonary resuscitation (CPR) and defibrillation can improve survival for Cardiac Arrest (CA) victims. In 2014, the rate of local bystander CPR was 50.6% and bystander defibrillation was 3.6%. Among the developed countries, Singapore had a low Utstein survival rate of 15.3% (2014). Utstein survival rate is a measure of survival for witnessed and shockable CA cases. Local CA cases has been on an upward trend due to the increasing proportion of elderly in Singapore. There was a need to have more publicly-accessible Automated External Defibrillators (AEDs), and to build a network of Community First Responders (CFRs) to respond to CA cases in their immediate vicinity Singapore is determined to improve our Utstein survival rate for our population. In line with our 2025 transformation vision of A Nation of Lifesavers, the Singapore Civil Defence Force (SCDF), together with the Ministry of Health (MOH), Singapore Heart Foundation (SHF) – social service agency promoting heart health, and People’s Association (PA) – public agency promoting social cohesion, launched the Save-A-Life (SAL) initiative in August 2015. SAL entails three components –(i) Hardware (installation of AEDs); (ii) Heartware (training on CPR-AED skills); and (iii) Software (activation of CFRs via the myResponder app to attend to CA cases within 400m of their location). SAL started with the objective of installing AEDs at lift lobbies of public housing because local research showed that 70% of local Out-of-Hospital Cardiac Arrest (OHCA) cases occurred at homes. It has since expanded to other areas. Under SAL, SCDF also expanded its voluntary public AED registry. The national Registry of AED integration (R-AEDi) project makes AED locations searchable via myResponder. With full implementation of subsequent phases of SAL, SCDF targets to have one AED within 250m reach of anyone in urban areas by end 2025.

SAL initiative empowers, equips and trains various segments of the community in lifesaving skills and ensuring that everyone has equal access to AEDs by increasing the availability of this vital lifesaving device in the community, especially in residential areas. The initiative promoted innovative uses of technology and leveraged the high smartphone penetration level in Singapore by crowdsourcing for CFRs to attend to CA victims through the myResponder app, and to administer CPR-AED as early as possible. Service delivery has also been transformed by adding a layer of CFRs to respond to cases before the arrival of SCDF.

(SDG 1.4) Anyone can access AEDs regardless of economic status. Most AEDs are located at public housing where over 80% of the population live. The myResponder is free and available on Google Play and App store. (SDG 3.6) SAL enables the co-delivery of public service for better outcomes. In addition to a response to CA cases, the activation to minor fires was added in 2018 and this allows SCDF to optimise its emergency resources to attend to higher-priority cases. (SDG 4.3) Everyone has equal opportunities to attend training (heartware). (SDG 10.3) Accessibility of AEDs is equitable across different population segments. Its high cost may be a deterrent to low-income households. By installing AEDs at public housing precinct, we ensure it is accessible and publicly visible. There is low barrier of entry to download the app and to register as a CFR. While the app is only available in English, this is the business language in Singapore. (SDG 11.5) Over 5,300 CFRs arrived on scene to render assistance. 41 lives were saved by CFRs who were either activated by the app and/or had utilised SAL AEDs (end Aug 2021). The Utstein survival rate improved from 15.3% in 2014 to 26.2% in 2019.

The majority of the AEDs are on lease where maintenance, repair and consumables are handled by a vendor. The myResponder app is also maintained by a vendor. All above mentioned cost outlays are borne by the government. The app is part of SCDF’s business and digital transformation towards 2025 and beyond. SCDF and its partners will continually engage the community to be trained in CPR-AED and register as CFRs through various outreach programmes. Moreover, the initiative promotes the self-help concept and ensures that the population is mentally resilient to manage emergencies prior to the arrival of SCDF.

It is currently not mandatory for building owners to install AEDs. Nonetheless, many buildings such as schools and community centres have chosen to do so. SAL has since made the AED more available in residential areas (1 AED installed in every 2 public housing blocks) and there are plans to install AEDs islandwide in condominiums and private estates in the future. In all, as of Sep 2021, through the initiative, over 5,500 AEDs have been installed at public housing lift lobbies, private condominiums, parks, park connectors, nature reserves, taxis, and private hire vehicles. While the ambulance will typically arrive in 11 minutes, every minute counts in a CA incident. The myResponder app fills in this gap by crowdsourcing to increase bystander CPR and bystander AED rate by alerting CFRs to nearby cases. The national AED registry provides equitable access for any CFR to locate the nearest AEDs and retrieve one on their way to the victim. Without the registry, CFRs may not be aware of the whereabouts of these AEDs. The AEDs listed in the database has increased rapidly from 2,284 in 2016 to 10,916 by October 2021. It continues to grow as organisations offer to share their AED location.

Gender is irrelevant in the purpose and mission of saving lives. Any CFR can make a difference because anyone can be equipped with the necessary skills and knowledge. Every CFR has the same opportunity to be trained and to attend to cases; the only factor affecting their chances is their proximity to the victim at the point of the incident.

SAL targets the general population as “beneficiaries” as anyone can suffer from CA (although age is a major risk factor). The OHCA results finds that more bystanders are stepping forward to help save lives. Bystander CPR rate improved from 50.6% in 2014 vs 61.8% in 2018; bystander AED usage has increased from 3.6% vs 7.2% in the same period. The Utstein survival rate has improved from 15.3% in 2014 to 26.2% in 2019. The overall survival rate improved from 4.1% in 2014 to 5.9% in 2018. SAL also targets the community as “service providers” as they bridge the critical interval between the onset of an incident and arrival of SCDF. They are encouraged to go through training and sign up as a CFR in myResponder and are also insured against injuries sustained when responding to incidents. Over 500,000 people have been trained in CPR-AED skills via various training platforms. As of October 2021, the app has over 184,000 downloads, with over 101,000 registered as CFRs. CFRs have attended to over 5,300 cardiac arrest incidents. The R-AEDi project which targets businesses/building owners to list their AEDs on the registry has expanded and provided CFRs greater visibility during emergencies.

The SAL initiative was piloted in six constituencies from Aug 2015 to Feb 2016. High elderly density was a factor in choosing the constituencies. AEDs were installed at the lift lobbies that have police cameras. A research agency was commissioned to conduct a survey involving residents from the six constituencies. Based on the favourable survey findings, SCDF subsequently launched the programme on a nation-wide basis. As an extension of the pilot phase, the “AED-on-Wheels” programme was launched with SMRT Taxis (local taxi company) in November 2015. AEDs were installed in 100 taxis with the drivers being alerted through the myResponder app to CA cases within a 1.5-kilometre radius of their location. This programme has expanded to more taxis and private hire vehicles. In 2017, SCDF began Phase 2 to install one AED in every 2 public housing blocks island-wide and completed it in February 2019. For new blocks, SCDF proceeded with the installation once the police cameras were operational. SCDF piloted the AED installation at condominiums in four constituencies (Phase 3) in July 2018. SCDF is one of the agencies supporting SGSecure Programme Office’s Safety & Security (S&S) Days in condominiums where AED installation at the guardhouse is offered as part of the event. Island-wide installation of AEDs in other condominiums will commence after the completion of S&S Days. SCDF is looking to collaborate with National Parks Board (NParks) to improve the AED coverage for the parks and park connectors in Singapore. NParks will be installing AEDs at all regional parks, major Park Connectors (PCNs) –an island-wide network of linear green corridors linking major parks and nature areas across Singapore, as well as within/near the vicinity of private estates (Phases 4 and 5).

At the beginning, SCDF faced challenges in getting the buy-in needed from partners like Town Councils and PA. Several meetings had to be conducted to seek their support before we could on-board them on the SAL initiative. Right from the start, SCDF decided to walk the ground with Town Council officials and staff from the Constituency Office to assess the suitability of the lift lobbies for AED installation, specifically on the exact and most suitable area to install the cabinet. This was to assure our community partners that the location of the AEDs had maximum visibility and accessibility for residents.

Besides providing AEDs (hardware) and the app to activate CFRs (software), the initiative recognises that the community must be equipped with CPR-AED skills (heartware). Hence SCDF collaborated with MOH for a shortened CPR-AED programme to cater to Singaporeans’ busy lifestyles. The myResponder app is the "first of its kind on a national level" to be integrated with the SCDF's emergency dispatch services, allowing SCDF to send alerts directly to CFRs. The R-AEDi project has improved the management of publicly available AEDs, and the programme to mobilise ‘AEDs-on-Wheels’ on a national scale was also the first-of-its-kind in Southeast Asia.

For the ‘AED-on-Wheels’ component, inspiration was drawn when private hire car services grew in popularity in the region. As more apps with geolocation services became prevalent, tapping on these users who were constantly on the move became a logical choice as they could respond faster and cover a wider area than a user on foot. Equipping such vehicles with AEDs and training the drivers with emergency preparedness skills then became the next logical step in building this business model of making AEDs and AED-CPR trained drivers more available and ready to respond to emergencies in their vicinity.

The development and scale-up of the app is aligned with the broader push for digital government services. The geo-location feature allows SCDF to locate CFRs within a 400m radius and send notifications to them. Response is entirely voluntary. Users can also alert SCDF of an incident via the app, enabling SCDF to expedite the deployment of CFRs and emergency resources. There are ongoing Proof-of-Concept trials to leverage drones to transport AEDs concurrently while activating CFRs – for even more immediate and easy access. This is especially crucial in areas where AED is not as readily available, such as large industrial premises.

Not to our knowledge. However, we have been recently approached (in Oct 2021) by Cebu City Fire Office, Philippines. They enquired on some details regarding our “AED-on-Wheels” programme and is looking into the possibility of adapting it in their city.

For example, a non-profit organisation, fire department or government can work together to kick start the initiative to proliferate AEDs in the community (hardware). Even if the country/city does not have high availability of AEDs, the local authorities can run a campaign to encourage residents to go for CPR training and make such trainings more readily available (heartware). The country/city can also develop an app like myResponder (software). Crowdsourcing apps are becoming increasingly common. Hence, with that technology, stakeholders could work with an app developer and activate users during emergencies. Even if there is no AED nearby, the bystander can proceed to the location shown in the app and perform CPR prior to the arrival of emergency responders. Moreover, bystander CPR has shown to increase survival rates. The concept of “AED-on-Wheels” can also be easily transferred, given that there are other forms of delivery networks that could be leveraged on to bring about the access to AEDs and CPR to more far-flung places. For example, governments can equip inter-state truck drivers with CPR-AED skills, and leverage their presence along the stretches of interstate highways that may not have as strong a presence of AEDs/emergency response capabilities.

Human resources from various entities involved were used to implement the initiative and they continue to ensure the various components of this initiative runs smoothly. Most of the funding is borne by the government, either through SCDF, its parent Ministry (Ministry of Home Affairs) or through Tote Board (statutory board under the Ministry of Finance) which channels the gaming revenue from Singapore Pools and Singapore Turf Club, together with the collection of casino entry levy, to support worthy causes in the community. A smaller portion of it, namely for the ‘AED-on-Wheels’ component (sponsorship of AEDs) come from partners.

SAL initiative will always receive unstinting support of relevant authorities because of its life-saving mission and the crucial role it places as part of SCDF emergency services chain of response. With Singapore’s aging population and impending labour crunch, it is crucial that the community step up and play its role during emergencies. A huge portion of SAL will continue to be funded by the government, enabling us to continue engaging vendors for vital components such as maintenance of myResponder app. SCDF will continue to work with partners to engage the community to pick up lifesaving skills thus enhancing community resilience.

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Forbes Research Pte Ltd was commissioned by SCDF to conduct a localised public perception survey involving 1,225 residents at the six pilot constituencies between February and April 2016. The objectives were to assess the public’s awareness, attitudes, and receptiveness towards SAL; to ascertain their willingness to step forward to render assistance to cardiac arrest victims; to determine the confidence level of the trained volunteers and residents; and to seek constructive feedback for island-wide installation. The SAL initiative and the myResponder app have won numerous local and regional awards. One example outside of Singapore is the ASEAN ICT Awards (Bronze) 2015.

The survey questionnaire was designed by Forbes using SCDF’s inputs and earlier pilot phase findings. The survey involved face-to-face interviews with 1,225 residents aged 15 years and above at their residences. It adopted the multi-stage sampling method to randomly select respondents from 160 public housing blocks where the AEDs were installed. There were about 8 face-to-face interviews conducted per block. The selected respondents mirrored closely the population demographic profile vis-à-vis dwelling type, age, race, and gender. The external assessment criteria include innovativeness/ benefits it has to the Public Service or public/ how the initiative contributes towards promoting citizen centricity.

Awareness level was high with 90.6% of respondents bring aware of at least one of the three components of SAL, with the highest awareness on the AEDs’ location (89.0%). 34.2% of respondents attended CPR and/or AED training. 40.1% were willing to register as CFRs via the app. 31.5% of the trained residents and 80.5% of non-trained residents indicated that they were unwilling to perform CPR/use the AED even when witnessing a victim (stranger). Trained residents were mainly worried about doing the wrong thing and faced with the consequences while non-trained residents were not confident. The vast majority (85.6%) of respondents supported the island-wide expansion of SAL. 86.4% of respondents also agreed that AEDs installed at the lift lobbies were conveniently located. The above findings served as a strong platform for the expansion of the SAL initiative. Hence, SCDF continued to install AEDs at lift lobbies including placing signages at visible locations. In our publicity efforts, SCDF continue to emphasise that the AED comes with step-by-step audio guide and even an untrained person calling 995 will be guided on execution of CPR. Suitable success stories were published on SCDF social media and traditional media to encourage wider participation.

SCDF is the lead agency responsible for implementing and managing SAL. We work closely with Ministry of Home Affairs (MHA) to provide updates and for funding support. SAL is a key enabler in our pursuit of building a nation of lifesavers, especially through continual partnership with everyday heroes and its tangible way of getting the community to sign up and be activated as responders. SAL is also one of the supporting instruments under SGSecure (programme launched by MHA in Sep 2016 to sensitise and sharpen Singapore’s community response to the threat of terrorism). Getting trained in CPR-AED skills will prepare residents for CA emergencies, thereby strengthening community’s resilience towards handling life-threatening emergencies. Since 2019, the app’s response feature has been integrated into SGSecure app, thereby extending its reach via additional SGSecure app downloads. We continue to promote the shortened CPR-AED course in our publicity efforts. Since 2017, the programme has received support from Ministry of Education and is promulgated to all Secondary 1 students under the Physical Education curriculum. This highlights support and recognition across different ministries on the importance of SAL and learning lifesaving skills. SCDF continues to work closely with PA and constituency-based Grassroots Organisations (GROs) for this initiative.

Before the pilot, MHA and SCDF sought the Town Councils’ approval on this installation, and informed Housing Development Board(statutory board) about this initiative. From Nov 2014 to Jan 2015, SCDF worked with PA to jointly organise meetings with the Grassroots Advisors, Town Council Managers and GROs to brief them on project and to seek their buy-in. The GROs took charge of mapping out the exact AED location within the public housing lift lobby and worked with the appointed vendor to install the AED. The GROs also helped to galvanise the residents in signing up and attending the CPR-AED training sessions. The public communications plan for the SAL initiative included localised publicity efforts in the form of posters, flyers, and Town Council/constituency newsletters to inform the residents on the initiative. Since 2015, SHF was engaged for the R-AEDi project as part of the SAL initiative. The deliverables include establishing and maintaining the national online AED Registry, engaging the public (e.g. through road shows), and conducting biennial survey of the Knowledge Attitudes and Practices regarding CPR and AEDs. As mentioned in Question 9, a survey involving residents from the pilot constituencies was conducted to seek constructive feedback and chart the way forward.

The initiative, especially the pilot phase, has shown the importance of working with the GROs. As such, the selection criteria of the constituencies for the pilot phase of AED installation at the private condominiums included a strong network of grassroots emergency preparedness advocates who would be willing to assist SCDF in galvanising the condominium residents to be trained in CPR-AED skills and the presence of existing grassroots (Neighbourhood Committees) linkages to the management of the condominiums. We will work through the grassroots for the island wide implementation as well. The myResponder app has gone through several enhancements since its launch. Upgrades include guided directions for responders to follow on the map while navigating to a case and for CFRs to subscribe to case notifications in preferred locations without being connected to GPS or even being physically there. We will continue to enhance the app to make it easier and more intuitive for CFRs to respond to cases. As for the ‘AED-on-Wheels’ programme, SCDF will continue to engage more companies to get their fleet on board the programme, such as logistics companies. We will also continue to advance community first response training for residents through continued partnership with GROs.