Because the chance of survival falls by an estimated 5% for each minute that passes between collapse and the start of CPR,1 bystander CPR is paramount for improving survival from out-of-hospital cardiac arrest (OHCA). Increasing the rate of bystander CPR can also be an effective and inexpensive way to enhance the chain of survival, compared to adding more first responders or other potential ways to shorten the time between arrest and the first chest compression.
Bystander CPR is a straightforward and potent intervention that can more than double the chance of survival but is provided in only 40% of cases nationwide.2 This situation persists despite large-scale public CPR training campaigns and an emphasis in recent years on compression-only CPR for adult arrests.
Telephone CPR (TCPR)–the provision of CPR instructions to the caller by the 911 telecommunicator–can be challenging from the moment a call is received: telecommunicators often face barriers to recognizing OHCA, starting CPR instructions once recognized, and maintaining contact with callers once CPR is underway. However, this intervention has been shown to dramatically increase bystander CPR rates and is associated with improved patient survival.3-5
TCPR is also perhaps the most efficient method of improving the chances of surviving cardiac arrest in a community. In King County, Wash., for example, nearly half of the bystanders who perform CPR receive direction from a telecommunicator.3 This strategy has been a powerful force in the county’s historic success responding to OHCA emergencies. For this reason, the HeartRescue Project partners focused time and energy on implementing and measuring this vital link in the chain of survival.
The Facts about TCPR
Telecommunicators face several challenges when receiving a 911 call for cardiac arrest. (See Table 1.) Callers are often distressed and difficult for call-takers to manage. They may be unclear or contradict themselves, leave the phone periodically, or even completely refuse to cooperate. In addition, OHCA patients often gasp for air (agonal breathing) or present brief, seizure-like symptoms that can confuse potential rescuers and telecommunicators alike.6
Calm, assertive telecommunicators can settle and guide frantic callers. They can control calls from the outset by letting callers know that help is on the way and by asking two guideline-recommended questions:
- Is the patient conscious?
- Is the patient breathing normally?7
If the answer to both questions is “no,” telecommunicators should start CPR instructions immediately, addressing callers with firm reassurance: “We need to start CPR–don’t worry, I’ll tell you how.” Instructions should be for compression-only CPR unless the arrest stems from a respiratory cause or occurs in a child less than nine years old. Such exceptional cases call for compressions and rescue breaths at a ratio of 30:2.
Once a potential cardiac arrest is identified, other barriers can delay or prevent the start of CPR. Callers often fear that compressions could hurt the patient. A study at the Resuscitation Academy in King County, however, found that the risk of injury is extremely low: Of 247 patients who received compressions though not in cardiac arrest, only six (2%) suffered injuries “likely or probably caused by bystander CPR.” Five suffered fractures, and there were no visceral organ injuries.8 Telecommunicators facing this objection, then, should assure callers that compressions are not only vital but also safe to perform.
Another common obstacle to effective bystander CPR occurs when callers have difficulty moving patients into position for compressions (e.g., from a bed, couch or chair to the floor). A study by the Save Heart in Arizona Registry and Education (SHARE) Program at the Arizona Department of Health Services found that, in cases where callers described a barrier to performing CPR, 83% of patients were found in positions other than on a hard, flat surface. Compressions were significantly less likely to be started and were significantly delayed relative to cases where callers didn’t report barriers. Yet females rescuing males were no less likely to start compressions on a hard, flat surface than were males rescuing females, and compressions were three-and-a-half times more likely to be started if multiple rescuers were present.9 Dispatchers, therefore, should encourage callers to persist in getting patients to the floor and utilize the help of other bystanders when possible.
Other barriers include the caller’s lack of confidence. They perceive CPR as a psychomotor skill too difficult to perform under the circumstances. Telecommunicators must support and affirm callers in such cases, assuring them they can do compressions and that they, the dispatchers, will guide them throughout the process.
Callers can also have an aversion to mouth-to-mouth contact (and the possibility of disease transmission) and a fear of legal consequences. The current standard for telecommunicator instructions is compression-only CPR, so there’s typically no need to consider mouth-to-mouth. If there are legal concerns, the telecommunicator can assure the caller that Good Samaritan laws exist to shield the citizen rescuer from liability. The caller’s actions can only help the patient.
In a recent nationwide survey assessing the kind of TCPR instructions provided, only 51% of the responding public safety answering points said they provide pre-arrival instructions for OHCA.10
When giving instructions, telecommunicators should tell callers to push hard and fast in the center of the chest and count their compressions out loud. This allows them to monitor the compression rate. The ideal rate is 100 beats per minute.
Through attentive, continuous coaching, telecommunicators can help callers achieve and maintain proper compression depth and rate until EMS arrives.
There are about 6,000 public safety answering points (PSAPs), or 911 call centers, in the United States. These include primary PSAPs, which answer all categories of 911 calls (fire, law enforcement and medical), and secondary PSAPs, which answer service-specific calls, such as medical emergencies. These 911 centers are run by municipal and county agencies, public safety agencies, third-party EMS agencies, law enforcement agencies and hospitals; other models exist as well.
The means by which 911 calls are received and processed isn’t standardized in the U.S. In many areas, calls are received by primary PSAPs and transmitted to secondary PSAPs with telecommunicators trained specifically in medical dispatch. In other cases, all 911 calls are processed at the primary call center. Despite a national scientific advisory statement in 2012 calling for compression-only CPR in adult arrests,7 there remains a large gap between guideline recommendations and actual practice. Of 1,924 PSAPs responding to a survey assessing the kind of TCPR instructions provided nationwide, only 51% said they provide pre-arrival instructions for OHCA, and only 3% said they provide compression-only instructions.10
Communities with effective TCPR programs improve TCPR through process measurement, system and case-level feedback to providers, and data linkage across the chain of survival. Process is measured by listening to OHCA audio recordings and evaluating, among other things, six key performance metrics:
- Did the telecommunicator recognize the cardiac arrest?
- Did the telecommunicator start CPR instructions?
- Did the lay rescuer initiate compressions as directed by the telecommunicator?
- How soon after call receipt at the medical 911 center did the telecommunicator recognize the cardiac arrest?
- How soon after call receipt did the telecommunicator start CPR instructions?
- How soon after call receipt did the lay rescuer start telecommunicator-directed compressions?
It’s important to track the barriers that prevent or delay the start of CPR as well. Identifying frequent obstacles is essential for adjusting protocols to overcome them.
Evaluating recordings is fundamental to improving quality of care and demonstrating the impact of TCPR on OHCA outcomes. A 2001 King County study found that telecommunicator-directed CPR increased the odds of survival for OHCA patients over those who received bystander CPR almost as much as CPR performed by bystanders who didn’t receive directions.3 Similar results in a statewide analysis were found in Arizona, where investigators adopted a TCPR quality improvement program based on the King County model.11 These findings indicate that CPR performed by a bystander who receives phone instructions may be as effective as CPR performed by a trained bystander.
Overcoming Barriers to Implementation
Evaluating recordings can be time-intensive work. It’s essential, however, and should be woven into a 911 center’s basic operations. Larger centers can receive hundreds of cardiac arrest calls a year. The cost of auditing each might be prohibitive, but there are solutions. Telecommunication managers can determine a feasible sample for review in a given period in order to gauge TCPR performance over time. This approach can highlight current needs and is an efficient way to begin this quality improvement effort. A free data collection tool, data dictionary and data entry webinar are available at www.mycares.net. In addition, online training modules are available at www.cprlinktolife.com and a Dispatcher Assisted CPR Toolkit is available on the Resuscitation Academy website at www.resuscitationacademy.com/index.php/resources.
TCPR appears to be grossly underutilized nationwide. Yet it represents a uniquely cost-effective approach to improving resuscitation outcomes, requiring only a modest capital investment–the communications infrastructure is already in place. For that reason, the Institute of Medicine (now the National Academy of Medicine) recommended developing national protocols and training standards for telecommunicator-assisted CPR in the landmark report, Strategies to Improve Cardiac Arrest Survival: A Time to Act.12
Properly trained telecommunicators applying guideline-based protocols can effectively identify OHCA and initiate bystander CPR through calm, assertive instruction to callers. They have the potential to turn untrained callers into effective providers and save thousands of lives across our communities every year.
International Academies of Emergency Dispatch Pushes for Faster Hands-on-Chest
As many as three-fourths of EMS agencies and 911 centers that are part of the HeartRescue Project use the International Academies of Emergency Dispatch (IAED) protocols, which have included evolving telephone CPR pathways for some 35 years. The IAED recognizes the critical importance of getting “hands on chest” as quickly as possible. The new version of the IAED protocol (version 13) provides a fast track to ensure dispatchers recognize the need for CPR quickly and safely. Using the software version of the protocols, dispatchers have been shown to be able to get hands on chest in as little as 20 seconds. The IAED has also launched an educational campaign to address a culture in which dispatchers are too risk adverse when it comes to starting CPR. For more information on these educational efforts, go to www.emergencydispatch.org.
–Brett Patterson, Chair, Medical Council of Standards, IAED
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12. Institute of Medicine. (June 30, 2015.) Strategies to improve cardiac arrest survival: A time to act. Retrieved Oct. 1, 2015, from http://iom.nationalacademies.org/Reports/2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx.