Background: Since 2008, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) has been running in Tehran, Iran. However, there are numerous cases that the emergency medical dispatchers (EMDs) did not provide DA-CPR or the bystander refused to perform CPR. The purpose of this study was to survey and identifypossible barriers to bystander resuscitation in out-of-hospital cardiac arrest (OHCA) cases.
Materials and methods: We used a mixed-method design, a qualitative approach using content analysis of record keeping and cross-sectional study. The study included audio recording of calls to Tehran Emergency Medical Service (EMS) for OHCA cases in 2017. First, a qualitative study was performed to establish the barriers. After identifying the barriers in the quantitative study, the frequency of different barriers was extracted. The causes of delay for cases outside the standard range were also reviewed.
Results: The audio files of 35 patients were assessed until the data saturation occurred in qualitative phase. Two main themes of “barriers of performing CPR” and “delay causes” were identified. In quantitative phase, information of 401 patients’ calls was analyzed. EMDs had diagnosed 334 patients (83.2%) with OHCA, of which 224 (55.8%) received CPR instructions, but just 189 (47.1%) cases were resuscitated by the bystander; in 157 (47.0%) cases the CPR was started with delay.
Conclusions: Based on the findings, “no cooperation of the bystander for psychological and unspecified reasons” was the most common category of identified causes for refusing to perform resuscitation. As well, “additional questions about medical history, age, gender, and incident” asked by the dispatcher was the most common cause of delay.
- Dispatch-Assisted CPR
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Out-of-hospital cardiac arrest (OHCA) is one of the global health problems with increasing statistics.1, 2 Although OHCA survival rate is generally low (with an average of 2–11% reported) it can be increased if cardiopulmonary resuscitation (CPR) is performed promptly and accurately.3, 4 Effective management of OHCA depends on the survival chain – a concept that explains the rapid initiation and integrated series of lifesaving actions.5 The chain begins with the early detection of cardiac arrest by a bystander and then continues as follows: the bystander decides on calling emergency medical service (EMS), s/he talks with an emergency medical dispatcher (EMD) to give primary information; the EMD dispatches an ambulance, and trains the bystander to do CPR until the ambulance arrives. It is claimed that properly performing this process can double the survival chance of OHCA cases.6
Recent studies have emphasized on training of CPR by dispatchers to bystanders as an effective intervention to increase performing CPR and the chance of survival.7 Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) involves the steps of recognition, engagement, and instruction. Practically, it means when a bystander calls the EMS at the incident scene, it is not merely a dispatch service but also it is an opportunity to expedite identification of cardiac arrest, and giving resuscitation by bystanders through systematic questions and answers and timely comprehensive instructions.5, 8 This approach has long been stablished in developed countries. In a study conducted during 10 years in Denmark, it was determined bystander CPR increased significantly, from 21.1% in 2001 to 44.9% in 2010; which also lead to significant increase of survival rate.9
In another study conducted in Singapore to evaluate the effects of a DA-CPR training program on bystander CPR rate and the outcomes of OHCA, the rate of CPR performed by bystanders was increased from 22.4% to 42.1% and return of spontaneous circulation (ROSC) increased significantly from 26.5% to 31.2% after the intervention.10 DA-CPR operating on standard protocols has been running since 2008 in Tehran. However, there are numerous cases that the dispatcher did not provide DA-CPR or the bystander refused to perform CPR despite receiving the dispatcher’s explanations. The same problems have been seen in various countries and various reasons have been recognized in this regard. These differences emphasize the need for performing similar studies in various regions of the world with different levels of public health and cultures.1 Therefore, this study was designed to survey and identify possible barriers of bystander performing CPR in OHCA cases in Tehran.
Materials and Methods
This study was conducted during 2019. We used a mixed-method design, qualitative content analysis of record keeping and cross-sectional study, respectively. The study included all audio recording of calls from January 1, to December 30, 2017, to Tehran EMS centers reporting OHCA cases. The excluding criteria included: dispatcher’s false cardiopulmonary arrest diagnosis; occurrence of cardiopulmonary arrest after the technician’s arrival in the patient’s location; cardiopulmonary arrest cases in medical centers such as clinics or the physician’s office; cardiopulmonary arrest due to trauma; cardiopulmonary arrest cases in <14 years old patients; certain deaths.
Qualitative Phase of the Study
First, a qualitative study was performed to establish the barriers in resuscitation by transcribing audio recordings. The primary sample size for the qualitative phase of the study (determining the barriers) was randomly selected 1% of the recorded audios per month; i.e. we randomly selected 1% per month of total OHCA case in 2017 for quantitative study. This 1% sample was merely the baseline sample for each month, and if data was not saturated with this rate, random sampling for that particular month was continued until reaching the data saturation. To synchronize the recorded voice and analysis, it was listened to several times and transcribed to Microsoft Word software where key sentences were extracted from the text.
The categories and subcategories for two main themes (barriers to perform and causes of delay) were extracted at the end of each voice transcription based on similarity and differences of the codes. Also, transcribed voice was reviewed and categories and subcategories were extracted independently and then cheeked again. This process was continued until questions and concept saturation. The categories and subcategories for two themes were discussed and revised to obtain the final concepts.
The analysis process for the qualitative study was performed with the content analysis approach based on the descriptions by Graneheim and colleagues.11 In the analysis process, the author first started with reading through all the transcripts to get a sense of the data as a whole. The researcher carried out manual coding of the transcripts separately. An inductive coding strategy (directed content analysis) was used as described by Graneheim et al. whereby the decision on appropriate coding themes was preceded the process of data analysis. According to this inductive approach, sometimes referred to as a data-driven approach, the codes were derived from the data that was not decided on beforehand. When the coding was completed, the authors identified similarities and differences in the coded material and created sub-categories that were clustered into main categories. The main categories laid the foundation for the creation of themes. We discussed codes, subcategories, main categories and themes until consensus was reached.
Quantitative Phase of the Study
The samples for the quantitative study were 460 audios recordings that was almost 10% of total OHCA case in 2017. The sample were selected based on multistage random sampling. First, number of samples was determined for each month based on 10% of audios recordings per month in 2017. Sampling for each month was conducted based-on systematic random sampling. If any case was excluded based on excluding criteria, another sample was randomly replaced the same month. After identifying the barriers based on the results of the qualitative study, the sample sounds for quantitative study were carefully listened to and the presence or absence of each barrier for each mission was extracted and included in the checklist. This checklist was prepared based on the results of the categories and subcategories of qualitative study.
In the quantitative study, in addition to the frequency of different barriers, the client’s demographic information and other information about the location of the incident of cardiopulmonary arrest were also extracted. Using a pre-prepared checklist, we evaluate the delays in initiating CPR, for cases where the EMD truly diagnosed cardiopulmonary arrest. Through listening to the recorded audios recordings, the time intervals of “call start” to “cardiac arrest identification,” “initiation of resuscitation instructions by EMD,” and “performing the first chest compression with bystander” were recorded. The causes of delay for cases outside the standard range specified by the American Heart Association guidelines were reviewed. According to the last recommendation of AHA, the minimally acceptable standard of the time interval between a call and OHCA identification should be less than 120 seconds; and the time interval between a call and doing the first chest compression should be less than 180 seconds.12
Values in the quantitative study were expressed as frequency (number and percentage), mean ± standard deviation (SD) and median (interquartile range). The Mann–Whitney U test was used for calculating the statistical difference between the median of two groups, like dispatcher’s work experience and call time in group with and without delay. Shapiro–Wilks test and graphical approaches were employed to check the normality assumption for the variable. Statistical analyses were performed using SPSS software, version 25 (SPSS Inc., Chicago, IL, USA).
Ethics approval was obtained from the ethics committee of Tehran University of Medical Sciences (IR.TUMS.VCR.REC.1397.1055). All data were used anonymously.
Qualitative Analysis Results
In total, the audio files of 35 patients were transcribed until the data saturation occurred. Based on the results of content analysis, two main themes of “barriers of performing CPR” and “delay causes” were identified. The barriers theme had six main categories and 16 subcategories, while the delay causes theme had two main categories and 13 subcategories. The six categories of “barriers of performing CPR” theme included: 1) dispatcher-related factors, 2) bystander’s inability to resuscitate, 3) no cooperation due to legal and religious concerns, 4) no cooperation for psychological and unspecified reasons, 5) patient-related factors, 6) environmental and communication-related factors.
For example, in the “barriers” theme, the psychological and unspecified reasons category, under the subcategory of “fear of non-compliance to do instructions,” the bystander says: “I can’t do it, I’m afraid of doing wrong actions.” Another bystander says: “I can’t do it, because I haven’t done it before.” In the subcategory of “dispatcher’s inability to control and manage the bystander’s stress,” the bystander states: “I can’t do anything, I’m scared, I’m shaking.” In the category of “no cooperation due to legal and religious concerns,” the subcategory of “lack of family relations with the patient,” the bystander describes his impediment of resuscitation as: “I have no relationship with him, we should wait for her children to arrive.” In “bystander’s inability to perform resuscitation” category, the subcategory of “bystander’s inability to move the patient,” the bystander described the hindrance to resuscitation as “I can’t move it, he’s too heavy.” In the category of “patient-related factors” and the subcategory of “lack of access to the patient,” the bystander states his reason not to perform resuscitation as: “I am far away, and she is not near me now.”
Table 1 presents categories, subcategories and an example of main theme code of “barriers of performing CPR” extracted from audio files. The two categories of “delay causes” theme included: 1) dispatcher-related factors with 3 sub-categories, and 2) environmental and bystander-related factors with 10 sub-categories. For instance, in the category of “environmental and bystander-related factors,” and the subcategory of “denying the need to start a resuscitation,” the bystander responds to request for resuscitation as: “He is dead, his skin turned blue, it is useless,” or the bystander states the reason for the delay in carrying out the orders: “He is dead, I will not touch him.” Table 2 presents categories, subcategories and an example of main theme code of “delay causes” extracted from audio files.
Table 1: Categories, subcategories and an example of main theme code of “barriers of performing CPR” extracted from audio files
Table 2: Categories, subcategories and an example of main theme code of “delay causes” extracted from audio files
Quantitative Analysis Results
Out of 460 audio recordings listened to, 59 were not analyzed, including calls from medical centers (n = 22), definitive death (n = 18), traumatic cardiac arrest (n = 12), and patients < 14 years old (n = 7). Finally, information of 401 patients’ calls was analyzed, of which 250 (62.3%) were male and 151 (37.7%) were female. The mean age of patients was 65.8±23 years. The mean times of dispatcher-bystander communication to determine consciousness, respiratory condition and sending the address to the ambulance-dispatching unit were 48±35, 100±68 and 70±63 seconds, respectively. The mean time from the onset of a call to the moment of cardiopulmonary arrest detection by the EMD as well as the mean time from the onset of a call to the moment of initiation of CPR instructions were 116±67 and 151±67 seconds, respectively. The mean time from the beginning of a call to the moment of doing the first chest compression was 193±77 seconds.
EMDs had diagnosed 334 patients (83.2%) with cardiopulmonary arrest, of which 224 (55.8%) received CPR instructions. Dispatchers did not recognize the need for resuscitation in 67 cases (16.7%) so CPR instructions were not given. Of the rest of the 224 cases that the dispatcher gave CPR instructions, 189 (47.1%) were resuscitated by the bystander (Figure 1).
Figure 1: The flowchart of studied cases
The frequency of identified types of barriers in resuscitation operations is given in Table 3. Accordingly, “no cooperation of the bystander for psychological and unspecified reasons” was the most common category of identified causes for refusing to perform resuscitation. However, “inability to control and manage the bystander’s stress” was the most common reason among subcategories.
Table 3: Frequency of identified types of barriers explained in people who did not perform CPR
Out of 334 (83.3%) who had been diagnosed as cardiac arrest cases by EMDs, in 157 (47.0%) cases the resuscitation was started with delay, 70 had more than a two minute delay in diagnosis (44.6%), 51 had more than a three minute delay in initiation of resuscitation instructions (32.5%), and 36 had more than a four minute delay in doing chest compression (22%). The frequency of identified types of causes of delay in the initiation of resuscitation is given in Table 4. Accordingly, among the subcategories, “additional questions about medical history, age, gender, and incident” asked by the dispatcher was the most common.
Table 4: Frequency of causes of delay in the initiation of CPR
The dispatchers’ work experience was between one to 120 months, mean 22.6±17.5 and median 18.0 (IQR=15). The test of normality and graphical approaches showed that dispatchers’ work experience did not have normal distribution in the delay variable (p<0.001) (Figure 2).
Figure 2: The dispatcher’s work experience (month) in the group with and without delay of more than 3 minutes in the initiation of CPR instructions
There was a significant relationship between the delay of more than three minutes in the initiation of CPR instructions and the dispatcher’s work experience. The median of dispatchers’ work experience in the group with delay in initiation of CPR was one-month fewer (18 vs. 19 months; P = 0.025) (Table 5).
Table 5: Distribution of delay in diagnosis over 1 minute, delay in initiation of instructions over 2 minutes, and their relationship to dispatchers’ work experience in Tehran EMS calls for OHCA in 2017
Patients who had delays in diagnosis and initiation of instructions mostly called in the middle of the night. That 25% of patients with delayed diagnosis called during midnight to 3 a.m., while patients without delay called during the interval of midnight to 4:30 a.m. This difference was also true for delayed onset of resuscitation instructions, and patients with delayed onset were more likely to call at midnight. The distribution of call time in groups with and without delay in doing chest compression was approximately the same, and none of the types of delays were associated with call time (Table 6).
Table 6: The distribution of call time in groups with and without delay in doing chest compression
However, the median difference between having delay or having no delay in initiating resuscitation instructions and call time was marginally significant, and patients with this type of delay compared to those without delay were more likely to call at midnight (P = 0.094).
As can be seen from the present study, in many OHCA cases, despite the bystander’s call to the dispatcher, resuscitation is not performed by the bystander until the ambulance arrives at the patient’s location. However, in cases where the bystander ultimately performs the CPR, there is a considerable delay that many factors are involved in it.
By an overview of different studies, it is found that barriers to perform and delays in the DA-CPR are common and are related to a mixture of reasons that may be attributed to the EMDs or bystanders. Different statistics have been reported the frequency of DA-CPR in various studies. For example, in a study conducted in United States, EMDs correctly identified OHCA in 80% of reviewed cases that this rate was the same as the findings of the current study. However, it should be considered that the median of a time interval from the onset of a call and OHCA diagnosis was 75 seconds in mentioned study, while in this study it was 116 ± 67 sec (it should be >120 seconds).
The time interval between the beginning of a call and doing the first chest compression was 176 seconds in mentioned study in comparison to this study that was 193 ± 77 sec (it should be >180 seconds). It is clear that although the statistics the in mentioned study did not reach the high performance of system standards, they were within the range of minimally acceptable standards; but the values in the current study are out of the standard range that emphasizes the need to improve interventions.13
A similar study was conducted to examine barriers of DA-CPR has been carried out in Singapore. The information of 1,157 recorded audios from July 2012 to March 2015 was analyzed. It was reported that in 97.5% the dispatcher nurse diagnosed that the patient needed CPR (83.3% in the present study) and only 2.5% of dispatchers did not recognize the need for CPR (16.7 % in the current study). The authors also reported that 91.3% of the time the dispatcher gave the resuscitation instructions to the bystander (56% in the present study), and only 6.2% CPR instructions were not given correctly (27.4% in the present study); also in 4.2% the bystander did not perform chest compressions (8.7% in the current study).14
These findings may be attributable to significant cultural differences that exist between a developed country such as Singapore compared to a developing country like Iran. The findings of the present study seem to indicate a pressing need for community-level education through various methods such as national media whose target audience is, in fact, the statistical community in need of education.
However, even some studies in developed countries such as the United States have reported very different results that are far from standards, which is worth considering. For example, in a study, it was reported that in almost 80% of the OHCA cases, EMDs even do not give DA-CPR instructions!8 This value was almost 45% in the current study conducted in Iran and less than 10% in the same study conducted in Singapore.14
The inability of bystanders to move the patient (37.2%), unwillingness to perform CPR (15%), and abrupt disconnection of the call (11%) were the most common barriers to initiate chest compression in the Ho et al. study. In the present study, “inability to control and manage the bystander’s stress,” “the bystander’s psychological condition,” and “giving inappropriate information by the bystander” were identified as the most common barriers to the bystander’s resuscitation, despite the dispatcher provided resuscitation instructions. These differences emphasize the need for similar studies in various regions of the world with different levels of public health and different cultures.1 Thus, in each area based on the common causes, relevant interventions should be considered. For example, in a study, the most important hindrance to perform CPR operations was transferring of calls from primary Public Safety Answering Points 15, which was not problematic in the present study.
Another study in this field examined 37,942 cases from January 2012 to December 2014 in South Korea.16 In this project, 44.8% received CPR according to the EMD’s Instructions (46.1% in the present study). Besides, in the mentioned study, only 4.8% of cases were not being resuscitated by the time of EMS arrival, which is about 55% in the present study. That is a considerable difference emphasizing the need to increase BLS education to the public in Iran.
Interestingly, in the South Korean study, in 30.7% of patients were resuscitated by the bystander without receiving the EMD’s CPR instructions. The results of another study also show that in 20.7% of cases calling EMDs, the bystander at the scene initiated the resuscitation15, which did not happen in this study.
Based on the findings of the current study, “no cooperation of the bystander for psychological and unspecified reasons” was the most common category of identified causes for refusing to perform resuscitation. As well, “additional questions about medical history, age, gender and incident” asked by the dispatcher was the most common cause of delay.
Acknowledgment: This study was conducted with the support of PreHospital and Hospital Emergency Research Center affiliated to Tehran University of Medical Sciences.
Conflict of interest: None to declare.
Funding: This study was founded with a grant from Tehran EMS Center.
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