Clinical paperUse of telephone CPR advice in Ireland: Uptake by callers and delays in the assessment process☆
Introduction
The role of telephone assisted cardiopulmonary resuscitation (T-CPR) has been well described, with evolving evidence that simplified procedures improve outcomes.1, 2, 3, 4, 5 The American Heart Association has recently summarised the data supporting the role of T-CPR in an advisory on improving survival in the community.6
However, limited data has been published on the effectiveness or outcomes of T-CPR. In 2014 Dameff et al. developed an audit framework for evaluation of 911 calls in a US dispatch centre which uses an automated computer aided dispatch system (Incident Management, version 8.1.3, Intergraph, Huntsville, AL).7 Of 317 cases in which CPR was indicated, it was already underway in 29.7%, and only 14% of cases had T-CPR delivered; where T-CPR was delivered the median time from start of call to first compression was 04:11 min (minutes:seconds format used throughout this paper). Lewis et al., reported in 2013 that median time to first T-CPR compression was 02:56 min, using a locally developed dispatcher training system in Seattle; they identified significant delays due to the questioning process and called for major improvement in this process.8
Stipulante et al. reported in 2014 on the implementation of a T-CPR regime in Belgium, using a French language, compression-only phone CPR algorithm and found that 22.5% of out-of-hospital cardiac arrest (OHCA) patients received T-CPR. They found that median time from call to first compression was 02:48 min after implementation of the regime, a significant improvement from the non-T-CPR situation.9
A 2013 study by Clegg et al. in the UK examined 50 consecutive suspected OHCAs by analysis of the times taken for each phase of the T-CPR interaction, using the Medical Priority Dispatch System Version 12 (Priority Dispatch Systems, Salt Lake City UT, US).10 They reported that mean time from call receipt to first compression was 04:45 min and that the time taken to determine if the patient was breathing was the longest single component (median 00:59 min).
A key issue in the appropriate use of T-CPR is the ability of dispatchers to recognise cardiac arrest. Dameff's study reported that dispatchers recognised the need for T-CPR in 79% of cases. Vaillencourt et al. reported in 2015 that dispatchers had a ‘fair sensitivity’ (65.9%) and ‘modest specificity’ (32.3%) in correctly diagnosing cardiac arrest during 911 calls in Canada, using dispatch algorithms developed by the Ontario Ministry of Health and Long-term Care.11
Ireland's National Ambulance Service (NAS) is undergoing rapid modernisation of its command and control systems. The NAS serves a population of 4.6 million in settings ranging from dense urban areas to remote and sparsely populated rural areas; around one-third of the population live in rural or small town environments. Highly effective dispatch systems are required to maximise the use of limited NAS resources; T-CPR, volunteer Cardiac First Responders, use of off-duty staff in OHCA, centralisation of command and control and high quality audit are among the measures which have been introduced.12
The NAS control systems use the Advanced Medical Priority Dispatch System (AMPDS) Version 12.0 which requires a call-taker to complete a series of 21 questions/items in order to diagnose cardiac arrest and then offer T-CPR.13 The AMPDS protocols are installed within a computerised system known as ProQA (Priority Dispatch Corporation, Salt Lake City, UT, US) which was used throughout this study; manual cards with the same questions are available in the control room if required. The NAS version includes all of the standard questions in the AMPDS protocol, with a number of repeated questions on address and appearance of the patient. It does not use specific questions about agonal breathing but has one additional question – ‘is the patient changing colour?’ Table 1 outlines the questions which essentially fall into four blocks:
- 1.
Location
- 2.
General assessment/what happened?
- 3.
Additional assessment/is there an AED nearby?
- 4.
Breathing assessment/establish cardiac arrest
At the time, call-takers/dispatchers within NAS control centres came from both clinical paramedic and non-clinical backgrounds. All received five days training in the use of the ProQA system, which is the computerised package based on the AMPDS protocols. This was followed by five days training on the overall Computer Aided Dispatch system. In 2015, the NAS moved to a single national control centre with almost exclusively non-clinical call-takers/dispatchers. We did not investigate the relationship between T-CPR and the characteristics or backgrounds of the call-takers/dispatchers involved.
This study aimed to examine the frequency of use of T-CPR in one regional control centre and to assess the time periods used for blocks of questions.
Section snippets
Methods
The national Out of Hospital Cardiac Arrest Register (OHCAR) provided details of all cardiac arrests reported in the study area between January 1st 2011 and December 31st 2012. The study area is served by a single regional ambulance control centre, at the time one of eight in Ireland. The area has a population of approximately 280,000 in predominantly rural settings. All calls identified by OHCAR use the unique identifier established at call receipt; this identifier is also used for recordings
Results
In the two year period, OHCAR identified 202 cases of cardiac arrest which had been dealt with by the ambulance service in the region, a rate of 36/105/year. This included 30/202 (14.9%) cases in which the patient was not in cardiac arrest at the time of the call for help to the Ambulance Service but arrested at some later point (seven in the presence of paramedics). Of the remaining 172 potential cases for T-CPR, complete PCRs and audio recordings were available for 145 individuals; the
Discussion
The finding that 202 cardiac arrests were managed by the Ambulance Service in a two year period indicates an incidence rate of 3/100,000/year, which is similar to that reported nationally.15, 16
It is notable that in 14.9% of cases, a caller had contacted the ambulance service before the patient suffered their cardiac arrest, so that in seven cases the arrest happened in the presence of the paramedic crew. Takei at el have recently suggested that survival rates are higher in such cases.17
It is
Conflict of interest statement
Neither author has any conflict of interest in this study. Neither has any financial or other influences in this piece of work. No funding has been provided for the study.
Gearóid Oman works as an Advanced Paramedic with the National Ambulance Service but does not work within the ambulance control centre where the data was gathered.
Acknowledgement
Siobhan Masterson, Project Manager, Out of Hospital Cardiac Arrest Register.
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Cited by (13)
2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
2019, ResuscitationCitation Excerpt :This evidence evaluation compared outcomes of patients who received bystander CPR as a result of DA-CPR with 2 groups of patients: those receiving no bystander CPR or those who received bystander CPR that was performed without dispatch assistance. Twenty observational cohort studies were identified,21,23,26–28,31–38,40–46 but only 10 of these studies included adjusted analysis.26,27,31–38 Because the clinical features of patients who received DA-CPR differed markedly from those of both the group who received no CPR and the group who received bystander CPR without dispatch assistance, only adjusted outcomes are reported.
A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children
2019, ResuscitationCitation Excerpt :These studies had very low certainty with serious risk of bias. For survival at hospital discharge both unadjusted16,18,20,22,29,34,36–38,40,41,48 (OR 1.67; [1.39, 2.0]) and adjusted18,38,40,48 analysis (AOR 1.40; [1.09, 1.78]) indicated benefit with DA-CPR. Data for ROSC, initial shockable rhythm and time to CPR all favoured DA-CPR (see Appendix G for details).
Targeted simulation and education to improve cardiac arrest recognition and telephone assisted CPR in an emergency medical communication centre
2017, ResuscitationCitation Excerpt :Recognition of arrest and prompt activation time by emergency medical dispatch are key process measures that have been shown to be associated with improved survival after sudden cardiac arrest.3,4 Several barriers to cardiac arrest recognition and telephone assisted CPR have been identified by various EMS systems, and while there are overlapping themes, there are also important differences that follow variations in language, culture and organisation.5–7 Misinterpretation of agonal breathing and seizures continue to challenge emergency medical communication centres (EMCC), despite centres reporting improvements after educational interventions.8–10
The authors reply: Comparing dispatcher assisted CPR versus trained bystander CPR
2017, American Journal of Emergency MedicineDispatcher assisted CPR: Is it still important to continue teaching lay bystander CPR?
2017, American Journal of Emergency MedicineCitation Excerpt :Cardiac compressions were started 105 s later in DACPR than in 4MACPRC. The DACPR collapse to compressions time, nearly 2 1/2 min, is consistent with other simulation studies [32] but in other on manikin [28,33] and real situation studies this time increases [20,26,27] and can exceed 5 min [34]. The following of CPR steps in the detection of CA was significantly worse in the DACPR experience than in the 4MACPRC, which coincides with some studies on real patients which estimate that CA detection by the dispatcher is around 43% [22].
Impact of dispatcher-assisted cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest: a systematic review
2021, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:http://dx.doi.org/10.1016/j.resuscitation.2016.02.006.