Helping Seattle’s VF survival rates top 50%
Recently Public Health–Seattle and King County, Wash., announced that more than 50% of patients in that city who suffered witnessed ventricular fibrillation (v-fib) survived cardiac arrest. Several factors have contributed to one the highest survival rates in the country. One of the most important is the role of emergency dispatchers.
As the first link in the Cardiac Arrest Chain of Survival, telecommunicators provide initial contact for 9-1-1 callers with the EMS system. But without a visual view of the patient, they must rely on the caller to provide critical information in a timely fashion. In King County, telecommunicators play a key role in reducing time spent identifying a cardiac arrest by asking every caller two questions:
“Is the patient conscious?”
“Is the patient breathing normally?“
If the answer to the first question is “yes,” the telecommunicator moves on to criteria related to other types of illness or injury. But if the answers to both questions are “no,” the caller is directed to immediately start CPR. Instructions are provided to those who don’t know CPR or need a reminder. Even those instructions have been modified slightly. Telecommunicators don’t bother telling the caller to bare the chest anymore. It takes too much time.
The King County telecommunicators are also equipped to assist in locating the nearest AED. Anyone who purchases an AED is strongly encouraged to register it with King County EMS. The information is placed in the CAD system, allowing telecommunicators to know if an AED is on site or located nearby.
The “all-caller interview”
The five communications centers in Seattle and King County handle approximately 161,000 medical emergency calls annually. Of those, only a small portion are cardiac arrests. According to Linda Culley, section manager, Community Programs, at King County EMS Division. King County, including Seattle, responds to about 1,140 cardiac arrest calls per year. Seattle and King County employ a two-tier system, staffed by 225 dispatchers, approximately 4,000 EMTS and 260 paramedics for a population of 1.8 million.
Although the all-caller interview seems straightforward, there are challenges. If the caller has limited English-speaking skills, the telecommunicator must ask the same questions in a different way to get the answer they need. They’ll ask: Can they respond to you? Can you wake them up? Is their chest raising and falling? Tell me what their breathing sounds like.
“The biggest problem is that if they don’t get a clean answer, they can go spiraling down the wrong pathway,” says Mickey Eisenberg, MD, PhD, medical director of King County EMS and professor of medicine at the University of Washington.
The single most significant dilemma faced by telecommunicators is the issue of agonal respirations. “Of all the pitfalls the dispatchers encounter, this one causes the most problems,” Culley says.
According to studies,1-3 the patient with agonal breaths has the greatest chance of survival, because this type of respirations occurs only in the first three to four minutes in v-fib cases. But it poses the greatest challenge to identify. “They are an indicator that there is still some flicker of life alive in the midbrain,” Eisenberg says.
Determining if the patient is breathing normally is the key. From the beginning, this word was included in the King County protocols. Eisenberg warns that some proprietary programs do not make this distinction, inadvertently causing difficulties for the dispatchers in recognizing a cardiac arrest.
Because information comes into dispatch chaotically, King County does not employ a strict question-based system in which dispatchers are required to proceed methodically through a pre-set series of questions. Instead, the protocols use a criteria-based system that acknowledges the way information comes to the dispatcher. Questions are provided, but telecommunicators don’t need to continue once they’ve identified the chief complaint. “We encourage them to use their training and good judgment,” Culley says.
Comm centers tend to have a high turnover rate for staff, making training a challenge. In King County, the telecommunicators are primarily civilians, while in Seattle, dispatch is staffed by firefighters.
A four- to six-hour course on dispatcher-assisted CPR and cardiac arrest is included in the 40 hours of emergency medical dispatch training all new telecommunicators receive. Eight hours of continuing education are required annually. This is accomplished through a four-hour classroom session and four hours of online training.
The cost of basic training is covered by the comm center. However, King County EMS pays the telecommunicator’s wages during the annual continuing education.
Eisenberg recommends working with comm center directors to establish a reasonable set of expectations. For example, the expectation might be that the comm center will identify a minimum of 50% of all cardiac arrests on the phone. Of those, they will provide dispatcher-assisted CPR 75% of the time.
“I would challenge every dispatch center in the nation to see if they can do it,” Eisenberg says.
The mantra at King County EMS is “Measure–Improve– Measure–Improve.”
“This is not going to magically happen,” Eisenberg warns. It’s important to learn from mistakes.
“[Nobody] will get it right on the first try,” Culley adds. The quality improvement process in King County is designed to be instructive, not punitive, she says.
All of the cardiac arrest calls must be reviewed by EMS, not just the calls that dispatch identified as cardiac arrest. Data must be collected on the cardiac calls dispatch missed, Eisenberg insists.
In King County, all cardiac arrest calls are recorded for review later. Summaries of the calls are provided to both the responders and the dispatch centers. “There has to be a partnership between the dispatchers and the EMS agency,” Eisenberg says. “We are not saying it’s easy, but we are saying it’s important.”
According to Eisenberg, telecommunicators must be asking themselves, “What could we have done to snatch life from the jaws of death?” “If they aren’t, [then] we aren’t doing our duty,” he says. “We feel that strongly about it,” he says.
A review of cases in which CPR chest compression instructions are given revealed that out of 247 patients, only six patients sustained injuries likely or possibly due to bystander CPR.4
Culley continues to encourage telecommunicators to be aggressive. “We believe in casting a wide net,” she says.
A critical element of the King County model is feedback. For every “save,” the EMS Division sends a letter to the telecommunicator involved, with a copy to that person’s supervisor. The telecommunicator also receives a special challenge coin, created by the EMS Division that features the quote,” To save one life is as if to save the world.”
At the end of the year, the Division presents an award at each of the comm centers to the telecommunicator who displays exemplary handling of a critical incident and a second award to the telecommunicator who displays exemplary sustained performance. The award for critical incident is often given to a dispatcher because of their exemplary response to a cardiac arrest case.
Some fire crews have even invited telecommunicators to dinner at the station as a special recognition for a job well done on a particular incident. Culley also suggests remembering the telecommunicator after a particularly difficult call.
Sharing what they’ve learned
Eisenberg is co-director of the recently launched the Seattle Resuscitation Academy, an intensive program presented by Seattle Medic One and King County EMS that is offered free of charge to EMS managers and directors from throughout the U.S. He says a Dispatcher Resuscitation Academy is being considered for the future. The one-day event would focus on how to establish a dispatcher-assisted CPR program including training and quality improvement elements.
Dispatch is a vital component of any EMS response, especially cardiac arrest. “People always talk about it, but at a much more fundamental level they have to embrace the concept that “˜I can make a difference in the outcome of this cardiac arrest,'” Eisenberg says.
In King County, they do.
- Clark JJ, Larsen MS, Culley LL, et al. Incidence of agonal respirations in sudden cardiac arrest. Ann Emerg Med. December 1992; 21:1464—1467. doi:10.1016/S0196-0644(05)80062-9
- Eisenberg M. Incidence and significance of gasping agonal respirations in cardiac arrest patients. Curr Opin Crit Care. 2006; 12:204—206. doi:10.1097/01.ccx.0000224862.48087.66
- Rea TD. Agonal respirations during cardiac arrest. Curr Opin Crit Care. June 2005; 11(3):188—191. Review. doi:10.1097/01.ccx.0000162095.08148.64
- White L, et al. Dispatcher-assisted cardiopulmonary resuscitation: Risks for patients not in cardiac arrest. Circulation. 2010; 121:91—97. doi:10.1161/CIRCULATIONAHA.109.872366