Clinical paperTime to identify cardiac arrest and provide dispatch-assisted cardio-pulmonary resuscitation in a criteria-based dispatch system☆
Introduction
The detection and provision of life-saving maneuvers for out-of-hospital cardiac arrests (OHCA) remains a major challenge in emergency medicine. Despite intense efforts, the overall survival rate for OHCA still does not exceed 8%.1 For years, it has been established that early cardio-pulmonary resuscitation (CPR) provided by bystanders is a key factor in improving the probability of survival, yet the rate of bystander CPR has remained low.2, 3 Dispatcher-assisted CPR (DA-CPR), in which dispatchers provide CPR instructions over the phone, is a procedure some dispatch centers have proposed as a complementary strategy in order to help bystanders to initiate CPR. DA-CPR may double the rate of CPR, although it has not yet been possible to demonstrate that DA-CPR by itself improves survival rates.4 Today, recognition of cardiac arrest (CA) and the immediate application of DA-CPR is essential,5 but no common framework or quality standards have been established in dispatch centers regarding, first, the target interval for recognizing OHCA and, second, the deliverance of DA-CPR. Limited knowledge exists regarding the barriers and negative determinants, which fact limits the recognition of OHCA and contributes to delaying or preventing the delivery of DA-CPR.6, 7 In a recent publication, the authors noted that the OHCA recognition rate was 92%, and the median time to recognize OHCA was 75 s. CPR was provided following DA-CPR in 62% of the cases, and the median time to first DA-CPR chest compression was 176 s.8 These results come from a dispatch center that is well-known for its excellent performances, and other reports have demonstrated significant variations both in delays to CA recognition and the proportion of DA-CPR proposal or DA-CPR application.
The primary goal of this study was to describe the proportion and the delays to recognizing CA and provide DA-CPR in a criteria-based dispatch (CBD). The second objective was to propose a template and performance indicators to be measured for OHCA dispatch studies, thus allowing benchmarking between dispatch centers.
Section snippets
Context
This study took place in the State of Vaud, Switzerland. A unique centralized CBD center covers a population of 750,000 and handles 80,000 calls per year. All dispatchers are paramedics or nurses with at least five years of field experience. Dispatchers benefit from 40 h of continuing education every year and are regularly evaluated to ensure that quality standards are met.
Dispatchers use guidelines based on callers’ descriptions of signs and symptoms, and they also rely on their own medical
Results
1679 primary OHCAs were treated by dispatch center during the study period, and 1256 (75%) met our inclusion criteria. Only two recordings were unavailable for review because of corrupted audio files (0.16%). Dispatchers could not assess OHCA in 14.5% (182/1254) of the cases. Dispatchers recognized OHCA in 71% (895/1254) of all cases and in 84% (895/1072) of cases for which an OHCA could be assessed. The dispatcher failed to recognize OHCA in 16.5% (177/1072) when it was possible to do so,
Discussion
Timely recognition of OHCA and the initiation of CPR by a layperson are the initial vital links of a successful chain of survival, for which a dispatcher plays a critical role. In this very large study of 1256 OHCA audiotapes, prospectively collected and analyzed in a dispatch center using a CBD system, we found that dispatchers were able to recognize OHCA in 71% of all reviewed cases and in 84% of the cases where OHCA was evaluable by the dispatcher. Cases with ongoing spontaneous bystander's
Limitations
This study is subject to several limitations. Our dispatchers are requested to stay on line with callers or to call back in the absence of other incoming calls. Therefore OHCAs may happen several minutes after a dispatcher receives the call if the patient was conscious at the beginning of the call. In dispatch centers where the dispatcher does not stay on the line, these calls may be categorized in the “OHCA not identified” or “patient conscious at the time of the call” and possibly excluded.
Conclusion
This study demonstrates that performances from a criteria-based dispatch system can be similar to those from a medical priority dispatch system regarding OHCA time recognition and DA-CPR delivery. Agonal breathing recognition remains the weakest link in this sensitive task in both systems
In order to improve benchmarking opportunities, we completed previously proposed performance standards propositions. It is of prime importance that all dispatch centers not only implement DA-CPR but also that
Conflict of interest statement
Fabrice Dami is the medical director of the state's dispatch. There are no other conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding sources
None.
Authors’ contributions
FD, MP, VF, PNC, OH planned and established the project, including the procedures for data collection, and they designed the paper. EH performed the analyses. FD drafted the first manuscript. All authors took part in rewriting and approved the final manuscript.
Acknowledgments
We would like to thank our dispatchers for their professionalism and ability to manage stressful situations, as well as for participating in our study to improve the efficiency of the chain of survival. We also thank all hospitals participating in this study for giving us access to their charts following the authorization of the Ethics Committee.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.09.390.