Emergency medical services (EMS) systems play an important role in bridging the gap between the citizens and the provision of appropriate emergency and critical care treatment. Calling a public emergency helpline such as 911 offers one of the first contacts with the receiving of emergency medical assistance. Call-takers in most of these centers are trained to offer citizen instruction in the application of cardiopulmonary resuscitation (CPR).
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The question remains as to the appropriate amount of medical training that these call-takers should receive. An international survey of the EMS medical directors of large urban EMS systems revealed that dispatchers with higher levels of training were less likely to identify the need for CPR and were less likely to give CPR instructions to the caller when compared to dispatchers trained solely in a protocolized dispatching program.
The authors conclude that more research is necessary to determine the appropriate level of training for EMS dispatchers to assure the optimal rescuer response to cardiac arrests in the field.
With the growing ability to provide care to citizens within the “out of hospital” arena, many EMS agencies across the world have utilized protocolized dispatching programs to effectively and efficiently respond to the wide breadth of medical complaints they encounter through 911 calls.1 Historically, it has been argued that in order to most proficiently utilize such protocols, a dispatcher requires only to be trained in the usage of the protocols, which has led to a level of training commonly referred to as Emergency Medical Dispatcher (EMD).
More advanced medical knowledge and training may distract the dispatcher from obtaining vital information and performing critical steps in time-sensitive situations. More recently, some EMS agencies have begun to use EMTs to answer calls, with the belief that their higher level of training renders them more effective at providing instruction to callers over the phone, and more able to instruct the callers in performing life-saving measures.
One important example of such instructional technique is in “dispatcher-assisted cardiopulmonary resuscitation” (DA-CPR) in the setting of out-of-hospital cardiac arrest (OHCA).
It has been shown that the time from onset of cardiac arrest to the administration of CPR is a critical factor in determining the likelihood of patient survival. Early initiation of CPR by bystanders improves survival.2-7 Unfortunately, despite efforts to increase the public’s ability and willingness to perform CPR, the frequency of bystander performed CPR remains low, with one study reporting as few as one third of patients who suffer out-of-hospital cardiac arrest received this intervention.7-8
Improving the rates of DA-CPR will improve OHCA survival. The authors wished to understand if the EMS medical directors of large urban systems shared the belief that enhanced medical training by 911 dispatchers would improve the administration of DA-CPR and thus improve survival from OHCA.
Materials and Methods
An international survey was conducted of the EMS medical directors of many of the largest cities in the world through the Metropolitan Municipalities EMS Medical Directors Alliance (The “Eagles” Coalition). This study was designed to determine the medical training required of 911 call center dispatchers.
These medical directors were additionally asked about the number of cardiac arrests they responded to in the most recent calendar year prior to the survey, the percentage of calls in which the need for telephone CPR was identified, and whether or not DA-CPR instructions were provided. The questions submitted to the members of the Coalition are listed in Table 1.
Data was collected from the individual surveys into a database (Microsoft Excel). Stratification was performed on the groups based upon the level of training for dispatch personnel for each agency.
Summations were performed for the number of cardiac arrest victims, the number of patients for whom the need for DA-CPR was identified, and the number of patients for whom DA-CPR instructions were provided.
If the agencies did not provide documentation of these numbers, they were eliminated from the statistical analysis. The relative proportions of patients receiving DA-CPR vs. level of dispatcher training were assessed.
Thirty-three EMS medical directors responded to the survey, representing over 53,000 OHCA victims for the year prior to the survey. Some 35,000 OHCA were represented by the 18 cities whose data was included in the analysis.
Of the EMS systems in which dispatcher training was solely at the EMD level, a total of 22,898 OHCA were represented. A total of 12,321 OHCA were included for systems that required medical training beyond EMD level.
The tabulated results are summarized in Table 2. Contrary to the hypothesis of the study, the authors found that a higher proportion of cardiac arrest calls received DA-CPR when dispatchers were trained at the EMD level, rather than at higher levels.
This international survey of the medical directors of 33 large urban EMS systems provided documentation regarding EMS calls for over 53,000 OHCA calls. Of the 18 systems included in the data analysis, 10 require that their dispatchers undergo training beyond that of their protocolized dispatch system.
According to the survey, this advanced training is typically EMT-B or paramedic level, though one system utilizes RNs to answer these calls. Interestingly, the data shows that OHCA arrest calls received by dispatchers with only EMD training had a higher percentage of recognition of the need for DA-CPR when compared to calls received by dispatchers with a higher level of training (77.1% vs 56%).
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EMD-trained dispatchers also demonstrated a higher percentage of OCHA calls where instructions for DA-CPR were actually provided (74.3% vs 43.4%). This finding could be explained by the historical proposition that additional training distracts dispatchers from efficiently obtaining necessary information from the callers and providing instructions.
However, as this was simply a voluntary survey with retrospective data, further study will be required to determine if EMS systems should utilize dispatchers trained only in protocolized dispatching programs or dispatchers with further medical training, such as EMTs.
There are several limitations to this study. First, this was a voluntary survey sent to EMS medical directors, so external validation of the data provided in the survey would be difficult.
Second, some respondents used estimated numbers for their data, leading to imprecise calculations.
Third, some respondents did not provide sufficient data to be included in the calculations, which may have led to incomplete reporting of data.
Finally, only a small number of systems required a higher level of training beyond EMS for their dispatchers, limiting the size of that reporting dataset.
The need for DA-CPR is recognized across the spectrum of emergency medical services. The most appropriate level of training for emergency medical dispatchers necessary to assure optimal utilization of DA-CPR requires additional validation. This study indicates that more fundamental training targeted toward specific protocol performance may increase the provision of DA-CPR.
1. Clawson, J. J., Martin, R. L., Cady, G. A., & Sinclair, R. (n.d.). EMD: Making the most of EMS. Retrieved December, 2019, from https://www.emergencydispatch.org/articles/themostofEMS.htm.
2. Ritter G, Wolfe RA, Goldstein S, et al. The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J. 1985;110(5):932-937. doi:10.1016/0002-8703(85)90187-5
3. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2011 Oct 11;124(15):e402]. Circulation. 2010;122(18 Suppl 3):S685-S705. doi:10.1161/CIRCULATIONAHA.110.970939
4. Bossaert L, Van Hoeyweghen R. Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest. The Cerebral Resuscitation Study Group. Resuscitation. 1989;17 Suppl:S55-S206. doi:10.1016/0300-9572(89)90091-9
5. Roth R, Stewart RD, Rogers K, Cannon GM. Out-of-hospital cardiac arrest: factors associated with survival. Ann Emerg Med. 1984;13(4):237-243. doi:10.1016/s0196-0644(84)80470-9
6. Song KJ, Shin SD, Park CB, et al. Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: a before-after population-based study. Resuscitation. 2014;85(1):34-41. doi:10.1016/j.resuscitation.2013.06.004
7. Koike, S., Ogawa, T., Tanabe, S. et al. Collapse-to-emergency medical service cardiopulmonary resuscitation interval and outcomes of out-of-hospital cardiopulmonary arrest: a nationwide observational study. Crit Care 15, R120 (2011) doi:10.1186/cc10219
8. McNally, Bryan, et al. “Out-of-Hospital Cardiac Arrest Surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005—December 31, 2010.” Morbidity and Mortality Weekly Report: Surveillance Summaries, vol. 60, no. 8, 2011, pp. 1—19. JSTOR, www.jstor.org/stable/24805770.