The authors reply, “A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in‐hospital setting”

The study by Davis et al. corroborates another recent study on deferred defibrillation in hospitals, which also showed poorer survival with the current American Heart Association/International Liaison Committee on Resuscitation deferred defibrillation guideline. The guideline itself resulted not from consideration of the 3-phase model as the authors appear to suggest, but rather from belated recognition that the long hands-off periods required by automated external defibrillators (AEDs) for rhythm analysis significantly decrease shock success and survival. However, the guideline was also applied to manual defibrillation, with no discernable rationale. The poor results from deferred defibrillation in hospitals may be largely due to the fact that the great majority of defibrillations in that setting are manual. Deferring defibrillation to mitigate hands-off time is completely inappropriate with manual defibrillation; with a manual device, a shock can be delivered in less than 5 seconds if done correctly. The present study supports the view that deferred defibrillation is ill advised and harmful with manual devices, particularly in hospitals. Distorting the guideline to cover manual devices has served to paper over a major shortcoming of AEDs vis-a-vis manual defibrillators and has likely caused unnecessary deaths. The guideline should be changed.