Elsevier

Resuscitation

Volume 85, Issue 2, February 2014, Pages 177-181
Resuscitation

Clinical Paper
Implementation of the ALERT algorithm, a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol, in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres

https://doi.org/10.1016/j.resuscitation.2013.10.005Get rights and content

Abstract

Objectives

Early bystander cardiopulmonary resuscitation (CPR) is a key factor in improving survival from out-of-hospital cardiac arrest (OHCA). The ALERT (Algorithme Liégeois d’Encadrement à la Réanimation par Téléphone) algorithm has the potential to help bystanders initiate CPR. This study evaluates the effectiveness of the implementation of this protocol in a non-Advanced Medical Priority Dispatch System area.

Methods

We designed a before and after study based on a 3-month retrospective assessment of victims of OHCA in 2009, before the implementation of the ALERT protocol in Liege emergency medical communication centre (EMCC), and the prospective evaluation of the same 3 months in 2011, immediately after the implementation.

Results

At the moment of the call, dispatchers were able to identify 233 OHCA in the first period and 235 in the second. Victims were predominantly male (59%, both periods), with mean ages of 64.1 and 63.9 years, respectively. In 2009, only 9.9% victims benefited from bystander CPR, this increased to 22.5% in 2011 (p < 0.0002). The main reasons for protocol under-utilisation were: assistance not offered by the dispatcher (42.3%), caller physically remote from the victim (20.6%). Median time from call to first compression, defined here as no flow time, was 253 s in 2009 and 168 s in 2011 (NS). Ten victims were admitted to hospital after ROSC in 2009 and 13 in 2011 (p = 0.09).

Conclusion

From the beginning and despite its under-utilisation, the ALERT protocol significantly improved the number of patients in whom bystander CPR was attempted.

Introduction

In Western countries, out of hospital cardiac arrest (OHCA) is a common event with a poor outcome. More than 90% of these victims will die before reaching the hospital, causing more than 300,000 deaths in United States each year a loss of life equivalent to that caused by the September 11 World Trade Centre attack every 3 days.1 Similarly, 275,000 Europeans suffering from OHCA are treated every year by Emergency Medical Systems (EMS).2, 3 Despite advances in public education concerning recognition of cardiac arrest, early notification of EMS centres and improvement in EMS service delivery, recent data indicate a persistent low rate of survival to hospital discharge; most of these suffer from disabilities.4, 5 There is a huge variety in worldwide survival, ranging from rates greater than 30% to just a few percent, representing the effects of local performance.2, 3, 6 Interestingly, the best local performances are systematically observed when the links of the chain of survival have been strengthened.6, 7

Previous study of OHCA revealed a low participation rate (13%) by lay people and 6% by family members in Belgium.8 However, 75–80% of OHCA occur at home, with a witness present half of the time.9 Reluctance to give rescue breaths, fear of communicable diseases, stress and apathy have been considered to be the main causes of such low participation rates.

The Chain of Survival paradigm depicts the key concepts and actions linking the victim of sudden cardiac arrest with survival.6 The first link of this chain reinforces the need for recognising patient with cardiac arrest and calling for help, while the central links emphasise integration of early cardiopulmonary resuscitation (CPR) as the fundamental component. Telephone-CPR (T-CPR) has the potential to increase bystander-provided CPR rates significantly, and could potentially double or even triple survival from OHCA.10, 11, 12, 13, 14 Therefore, guidelines have recommended encouraging telephone guided-chest compression only CPR for untrained volunteers.9

In Belgium, a wide range of time to provision of basic life support by EMS crews has been reported, reinforcing the need for early bystander T-CPR.8 Indeed, it is likely that the dispatcher giving telephone advice on providing CPR will be speaking with a relative of the victim.15

We previously demonstrated that the ALERT algorithm (Algorithme Liégeois d’Encadrement à la Réanimation par Téléphone), a French-language compression-only phone CPR protocol, had the potential to help bystanders initiate CPR.16

Improving the quality of our EMS services in accordance with current guidelines required the implementation of this protocol in our country, including evaluation of its efficacy. We therefore designed the present study to evaluate the short-term effects of the implementation of this protocol.

Section snippets

Setting

The ALERT protocol provides a strictly worded step by step algorithm to help the bystander initiate CPR. Before airway management, bystanders are asked to place the victim supine on a hard surface, if possible on the ground, with the bystander kneeling next to the victim's chest.17, 18 Then, the need for CPR is determined using a check for responsiveness, airway opening manoeuvres and search for normal spontaneous breathing. When needed according to the algorithm, CPR chest-compression only is

Study population (Fig. 1)

During study periods I and II, the dispatching centre handled a total of 67,606 and 53,223 incoming calls, respectively.

Potential OHCA calls leading to deployment of SMUR occurred on 792 occasions during period I, and 777 during period II.

Based on these interventions, interrogation of the SMURREG database of on-site EMS interventions confirmed 286 OHCA during period I, and 314 during the period II.

At the moment of the call, dispatchers were able to identify 233 (81.5%) of these OHCA during

Discussion

The low rate of bystander CPR participation in Belgium led us to develop an original T-CPR algorithm, the ALERT protocol. In a preliminary manikin study, we demonstrated that this protocol had the potential to help both previously trained and untrained bystanders initiate CPR.16 Based on these results, the BFPHS decided to further implement this T-CPR system throughout the EMCC in the country, with the aim of strengthening the links of the survival chain, and ultimately the survival rates from

Conclusions

These results indicate that the implementation of the ALERT algorithm, a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol, in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres significantly improved the numbers of patients in whom bystander CPR was attempted, despite its initial under use.

Conflict of interest statement

No conflict of interest declared.

References (35)

Cited by (53)

  • European Resuscitation Council Guidelines 2021: Systems saving lives

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    ILCOR also recommends that dispatch centres look for ways to optimise their sensitivity to recognise cardiac arrest (minimise false negatives).11 This strong recommendation was based on very-low certainty evidence drawn from 46 observational studies which included 789,004 adult OHCAs reporting recognition of arrest varying between 46% and 98% and a specificity varying between 32% and 100%.27,28,79,131–172 The review concluded that the studies were too heterogeneous for head-to-head comparisons of different criteria, algorithms, dispatcher background or training, and the diagnostic capabilities varied greatly within all the various categories with no clear patterns emerging.

  • A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children

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    Certainty of evidence was assessed as very low for all analyses. Survival was reported at three time-points: hospital admission (unadjusted six studies17,24,28,35,42,46 adjusted one study28); one-month (unadjusted two studies26,28; adjusted two studies26,28) and at hospital discharge (unadjusted seven studies16,19,29,32,42,43,46; adjusted one study42). Systems with Dispatcher-Assisted CPR programs were not associated with significantly improved survival at any time-point in unadjusted analyses, although the point estimate suggested benefit.

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