Telephone-assisted CPR: A literature review

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

Background

The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre.

Methods

This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation.

Results

Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted.

Conclusion

Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Compression-Only or Standard Cardiopulmonary Resuscitation for Trained Laypersons in Out-of-Hospital Cardiac Arrest: A Nationwide Randomized Trial in Sweden

BACKGROUND

The ongoing TANGO2 (Telephone Assisted CPR. AN evaluation of efficacy amonGst cOmpression only and standard CPR) trial is designed to evaluate whether compression-only cardiopulmonary resuscitation (CPR) by trained laypersons is noninferior to standard CPR in adult out-of-hospital cardiac arrest. This pilot study assesses feasibility, safety, and intermediate clinical outcomes as part of the larger TANGO2 survival trial.

METHODS

Emergency medical dispatch calls of suspected out-of-hospital cardiac arrest were screened for inclusion at 18 dispatch centers in Sweden between January 1, 2017, and March 12, 2020. Inclusion criteria were witnessed event, bystander on the scene with previous CPR training, age above 18 years of age, and no signs of trauma, pregnancy, or intoxication. Cases were randomized 1:1 at the dispatch center to either instructions to perform compression-only CPR (intervention) or instructions to perform standard CPR (control). Feasibility included evaluation of inclusion, randomization, and adherence to protocol. Safety measures were time to emergency medical service dispatch CPR instructions, and to start of CPR, intermediate clinical outcome was defined as 1-day survival.

RESULTS

Of 11 838 calls of suspected out-of-hospital cardiac arrest screened for inclusion, 2168 were randomized and 1250 (57.7%) were out-of-hospital cardiac arrests treated by the emergency medical service. Of these, 640 were assigned to intervention and 610 to control. Crossover from intervention to control occurred in 16.3% and from control to intervention in 18.5%. The median time from emergency call to ambulance dispatch was 1 minute and 36 s (interquartile range, 1.1-2.2) in the intervention group and 1 minute and 30 s (interquartile range, 1.1-2.2) in the control group. Survival to 1 day was 28.6% versus 28.4% (P=0.984) for intervention and control, respectively.

CONCLUSIONS

In this national randomized pilot trial, compression-only CPR versus standard CPR by trained laypersons was feasible. No differences in safety measures or short-term survival were found between the 2 strategies. Efforts to reduce crossover are important and may strengthen the ongoing main trial that will assess differences in long-term survival.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02401633.

Out of hospital cardiac arrest, first steps to know and follow in Mexico to have cardioprotected territories. A point of view of a group of experts

Sudden cardiac death is a common occurrence. Out-of-hospital cardiac arrest is a global public health problem suffered by ≈3.8 million people annually. Progress has been made in the knowledge of this disease, its prevention, and treatment; however, most events occur in people without a previous diagnosis of heart disease. Due to its multifactorial and complex nature, it represents a challenge in public health, so it led us to work in a consensus to achieve the implementation of cardioprotected areas in Mexico as a priority mechanism to treat these events. Public access cardiopulmonary resuscitation (CPR) and early defibrillation require training of non-medical personnel, who are usually the first responders in the chain of survival. They should be able to establish a basic and efficient CPR and use of the automatic external defibrillator (AED) until the emergency services arrive at the scene of the incident. Some of the current problems in Mexico and alternative solutions for them are addressed in the present work.

The understandability and quality of telephone-guided bystander cardiopulmonary resuscitation in the Western Cape province of South Africa: A manikin-based study

Background

The incidence of cardiovascular disease is on the increase in Africa and with it, an increase in the incidence of out-of-hospital cardiac arrest (OHCA). OHCA carries a high mortality, especially in low-resource settings. Interventions to treat OHCA, such as mass cardiopulmonary resuscitation (CPR) training campaigns are costly. One cost-effective and scalable intervention is telephone-guided bystander CPR (tCPR). Little data exists regarding the quality of tCPR. This study aimed to determine quality of tCPR in untrained members of the public. Participants were also asked to provide their views on the understandability of the tCPR instructions.

Methods

This study followed a prospective, simulation-based observational study design. Adult laypeople who have not had previous CPR training were recruited at public CPR training events and asked to perform CPR on a manikin. Quality was assessed in terms of hand placement, compression rate, compression depth, chest recoil, and chest exposure. tCPR instructions were provided by a trained medical provider, via loudspeaker. Participants were also asked to complete a short questionnaire afterwards, detailing the understandability of the tCPR instructions. Data were analysed descriptively and compared to recommended quality guidance.

Results

Fifty participants were enrolled. Hand placement was accurate in 74 % (n = 37) of participants, while compression depth and chest recoil only had compliance in 20 % (n = 10) and 24 % (n = 12) of participants, respectively. The mean compression rate was within guidelines in just under half (48 %, n = 24) of all participants. Only 20 (40 %) participants exposed the manikin's chest. Only 46 % (n = 23) of participants felt that the overall descriptions offered during the tCPR guidance were understandable, while 80 % (n = 40) and 36 % (n = 18) felt that the instructions on hand placement and compression rate were understandable, respectively. Lastly, 94 % (n = 47) of participants agreed that they would be more likely to perform bystander CPR if they were provided with tCPR.

Conclusion

The quality of CPR performed by laypersons is generally suboptimal and this may affect patient outcomes. There is an urgent need to develop more understandable tCPR algorithms that may encourage bystanders to start CPR and optimise its quality.

Evaluation of Telephone Cardiopulmonary Resuscitation Performance in Current Practice in Saudi Arabia

Objectives

Out-of-hospital cardiac arrest (OHCA) is a global health problem with a low survival rate. Telephone cardiopulmonary resuscitation (T-CPR) guidance by emergency medical services (EMS) dispatchers can improve CPR performance and, consequently, survival rates. Accordingly, the American Heart Association (AHA) has released performance standards for T-CPR in current practice to improve its quality. However, no study has examined T-CPR performance in Saudi Arabia. Therefore, this study aims to evaluate T-CPR performance in the Saudi Arabian EMS system.

Methods

A retrospective observation of OHCA calls in current practice was conducted in Riyadh, Saudi Arabia. OHCA calls were reviewed to identify those that met the selection criteria. Variables collected included return of spontaneous circulation (ROSC), OHCA recognition rate, time from EMS call receipt to location acquisition, to OHCA recognition and to commencement of CPR.

Results

A total of 308 OHCA cases were reviewed, and 100 calls were included. ROSC was identified in 10% of the included calls. OHCA was correctly recognized in 62% of the calls. The time to OHCA identification and CPR performance from EMS call receipt were found to be 303 s and 367 s, respectively.

Conclusion

T-CPR performance in Saudi Arabia is below AHA standards. However, this is similar to what has been reported in the literature. Avoiding any unnecessary call transfer during OHCA calls and prompt identification of callers' locations could improve T-CPR performance.

Video characteristics for remote recognition of agonal respiration: A pilot study

Aim

The mobile network quality in ambulances can be variable and limited. This pilot study aimed to identify a suitable network setting for recognizing agonal respiration under limited network conditions.

Methods

We recruited five emergency medical technicians, and each participant viewed 30 real-life videos with different resolutions, frame rates, and network scenarios. Thereafter, they reported the respiration pattern of the patient and identified agonal respiration cases. The time at which agonal respiration was identified was also recorded. The answers provided by the five participants were compared with those of two emergency physicians to compare the accuracy and time delay in breathing pattern recognition.

Results

The overall accuracy for initial respiratory pattern recognition was 80.7% (121/150). The accuracy for normal breathing was 93.3% (28/30), for not breathing was 96% (48/50), and for agonal breathing was 64.3% (45/70). There was no significant difference in successful recognition between video resolutions. However, the rate of time delay in recognizing agonal respiration less than 10 seconds between 15-fps group and 30-fps group had statistical significance (21% vs 52%, p = 0.041).

Conclusion

The frame rate emerges as one of critical factors in agonal respiration recognition through telemedicine, outweighing the significance of video resolution.

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study

BACKGROUND

T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival.

OBJECTIVE

To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan.

METHODS

A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant.

RESULTS

There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.).

CONCLUSION

Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

[Why do we need cardiac arrest centers?]

In patients with out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC) following cardiopulmonary resuscitation (CPR), the prognosis is influenced by various factors. In the prehospital setting, the duration of ischemia from the time of onset of cardiac arrest to the beginning of effective resuscitation measures is by far the most critical and determining factor for outcome. This interval can be shortened by an increase in the rate of lay CPR measures. With respect to intrahospital follow-up care, a number of structural factors have a relevant influence on prognosis. According to the literature, case volume, size of the hospital and the number of post-OHCA patients treated per year also have a large influence on the further prognosis. The crucial factor here is the availability and permanent readiness of a catheterization laboratory with the possibility of an immediate coronary intervention. In OHCA patients with ST-segment elevation myocardial infarction (STEMI), the time passed until the reopening of the occluded infarcted vessel is of paramount importance for survival. The 24/7 around the clock availability of a catheterization laboratory is therefore one of the indispensable prerequisites for a cardiac arrest center (CAC). In addition, a number of technical, structural, and organizational arrangements must be implemented in the CAC clinics in order to fulfil the requirements for such a center. The certification of CACs is currently being implemented by the German Resuscitation Council (GRC) and the German Society of Cardiology (DGK). As an important aim the GRC and the medical societies involved are hoping to avoid misallocation of post-OHCA patients to the nearest hospital, which may not be a suitable center for the treatment of these patients. Future studies will show whether CACs can indeed comprehensively improve the prognosis of OHCA patients following successful prehospital resuscitation.

[Degree of implementation of structured answering of emergency calls in German emergency dispatch centers and effects of the introduction in daily practice]

BACKGROUND

The emergency call-taking process is crucial for the adequate disposition of emergency vehicles and the provision of first aid instructions. Moreover, it has a direct impact on the quality of out-of-hospital emergency care. Organizations such as the European Resuscitation Council, the German Federal Association of Emergency Medical Directors and the German Association of Emergency Dispatch Centers call for the nationwide implementation of a formal call-taking process in emergency dispatching. This is required for the provision of telephone-assisted cardiopulmonary resuscitation (T-CPR).

METHODS

This article presents the results of an online survey among members of the German Association of Emergency Dispatch Centers on the implementation of structured call-taking programs. The survey comprised data on the implementation of a structured call-taking process, its effects on important quality indicators such as the frequency of T‑CPR and employee satisfaction.

RESULTS

Of the 100 participants who completed the survey, 49 already used formal call-taking systems and 24 (47%) of the remaining 51 emergency dispatch centers intended to implement such a system. Formal call-taking systems were mainly used in the dispatch of emergency medical services (98% of emergency dispatch centers using a formal call-taking system) and fire brigades (83.7% of emergency dispatch centers using a formal call-taking system). In 42 (85.7%) of the 49 emergency dispatch centers using a formal call-taking process, this process is mandatory; however, only 27 (64.3%) reported compliance rates of more than 95% in medical emergencies. Comparing the pre-post results after the introduction of a structured approach, the quality of the inquiries improved for almost all emergency dispatch centers. On the other hand, important quality indicators, e.g. mean dispatch initiation time or the necessity of subsequently alerting an advanced life support unit to the scene, were not recorded in 42.9% and 49.0% of the dispatch centers, respectively. Of the emergency dispatch centers that analyzed the frequency of T‑CPR, 94.3% could show an increase in T‑CPR. Moreover, 79.5% of the respondents reported improved employee satisfaction. Whereas the demand for dispatchers remained nearly static, 24 out of the 49 dispatch centers that used a formal call-taking system set up new posts for quality management (maximum: 3 posts in dispatch centers handling more than 250,000 missions annually).

CONCLUSION

Structured emergency call-taking has not yet been comprehensively implemented in German emergency dispatch centers. Wherever it is used consistently, important quality parameters are improved. Further investigations should aim to identify crucial factors for its implementation and to analyze additional quality parameters.

Using a smartphone application (PocketCPR) to determine CPR quality in a bystander CPR scenario - A manikin trial

PURPOSE OF THE STUDY

Feedback devices and dispatcher assistance increase CPR quality in bystander resuscitation. Yet, there is no data comparing both approaches with uninstructed CPR. The present prospective, randomized, controlled, manikin trial aims to determine the effects of the use of a smartphone application (PocketCPR) on CPR quality in a bystander CPR scenario compared to dispatcher-assisted telephone CPR and uninstructed CPR.

METHODS

100 laypersons were included to perform 8-min CPR on a manikin. Volunteers were randomly assigned to one of four groups: (1) uninstructed CPR (uninstructed group), (2) dispatcher-assisted telephone CPR (telephone-group), (3) guidance and feedback through a smartphone application (app-group) and (4) dispatcher-assisted telephone CPR combined with the smartphone-app (telephone + app-group).

RESULTS AND DISCUSSION

There was no significant difference in the time to first compression between the uninstructed and the app-group (p = 0.052), likewise between the telephone- and the telephone + app-group (p = 0.193). The no-flow-time of the uninstructed group was significantly longer compared to all other groups (p < 0.001). Median compression rate was significantly higher and within the recommended range in the app- and the telephone + app-group. There was no significant difference regarding correct compression depth between the four groups. Correct hand position and complete thorax release was found significantly more frequently in groups with smartphone-app support.

CONCLUSIONS

Feedback by a smartphone application can improve bystander CPR quality in terms of no-flow-time, compression rate, correct hand position, thorax release and does not delay CPR onset. However, the use of a smartphone application does not improve compression depth significantly.