Assessment of a quality improvement programme to improve telephone dispatchers' accuracy in identifying out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest research progress and challenges in Lithuania

Aim

To present the evolution of data collection and analysis methods of out-of-hospital cardiac arrest (OHCA) research in Kaunas city, Lithuania, and discuss the challenges encountered.

Methods

In late 2016, data collection began with a focus on 2016 data, following the Utstein 2014 template. The Kaunas city emergency medical services (EMS) station, which has a protocol dispatch system, pioneered the use of electronic submissions for the national EMS data collection form, making the research process more efficient. Most OHCA patients were treated in a tertiary university hospital which transitioned to electronic health record system in 2017, improving data accessibility. Throughout data collection significant efforts have been directed towards enhancing process efficiency and simplifying operations. As a result, the expansion of the Excel data table led to the creation of the ''resuscitation registry form' 'in 2018, which became operational in 2020.

Results

The collected data were used in several observational studies to identify and better outcomes.

Conclusion

Engaging in research on OHCA is difficult and poses many unique challenges owning to the urgency of the condition, complexity of legal and ethical considerations, and implications of any research intervention. The lack of a connection between the EMS and hospital electronic health record systems poses challenges for data collection. Legal and ethical complexities, including mandatory initiation of resuscitation and challenges in obtaining ethical approval, highlight the need for a comprehensive framework. This study aims transition the accumulated expertise into a nationally recognised registry for OHCA.

Dispatchers trained in persuasive communication techniques improved the effectiveness of dispatcher-assisted cardiopulmonary resuscitation

BACKGROUND

Early recognition of cardiac arrest and early initiation of bystander cardiopulmonary resuscitation can increase the survival of patients with out-of-hospital cardiac arrest (OHCA). We compared dispatcher-assisted cardiopulmonary resuscitation (DACPR) effectiveness before and after using different communication models in the dispatching center.

METHOD

We analyzed dispatch recordings of non-trauma origin OHCA cases received by the Taichung dispatch center between May 1 to September 30, 2021, and November 1, 2021, to March 31, 2022. The dispatchers underwent an 8-hour training intervention consisting of targeted education using a new communication model for DACPR. Several outcome measures were evaluated, including the sustained return of spontaneous circulation and the time to first chest compression.

RESULTS

We included 640 cases in the preintervention group and 580 cases in the postintervention group. The return of spontaneous circulation (ROSC) rate, the time to first chest compression, and good neurological outcome were significantly improved in the postintervention group (20.9% vs. 31.0%, p < 0.001;168 seconds vs. 151 seconds, p = 0.004; 2.8% vs. 5.3%, p = 0.024, respectively). In subgroup analyses, the intervention was related to a statistical improvement in ROSC rate among patients whose caller was a family member (18.7% vs. 31.4%, p < 0.001). Among patients whose caller was female, both ROSC and good neurological outcome significantly improved after the intervention (19.8% vs. 36.6%, p < 0.001; 2.7% vs. 7.5%, p = 0.006, respectively). There was a statistical difference between the pre-intervention and post-intervention group with respect to ROSC rate among patients whose caller was family (the adjusted odds ratio:1.78, 95% CI: 0.59-1.25], p < 0.001.) or female (the adjusted odds ratio:3.18,95% CI: 1.77-5.70], p = 0.008.) in the multivariable regression model.

CONCLUSION

The new communication model has enhanced the effectiveness of DACPR in terms of the ROSC rate, particularly when the caller was a family member or female, leading to improved rates of ROSC and favorable neurological outcomes.

Identifying patients at imminent risk of out-of-hospital cardiac arrest during the Emergency Medical call: The views of call-takers

Introduction

There is little research on the triage of patients who are not yet in cardiac arrest when the emergency call is initiated, but who deteriorate and suffer a cardiac arrest during the prehospital phase of care. The aim of this study was to investigate Emergency Operation Centre staff views on ways to improve the early identification of patients who are at imminent risk of cardiac arrest, and the barriers to achieving this.

Methods

A qualitative interview and focus group study was conducted in two large Emergency Medical Services in England, United Kingdom. Twelve semi-structured interviews and one focus group were completed with Emergency Operations Centre staff. Data were analysed using reflexive thematic analysis.

Results

Three main themes were identified: The dispatch protocol and call-taker audit; Identifying and responding to deteriorating patients; Education, knowledge and skills. Barriers to recognising patients at imminent risk of cardiac arrest include a restrictive dispatch protocol, limited opportunity to monitor a patient, compliance auditing and inadequate education. Clinician support is not always optimal, and a lack of patient outcome feedback restricts dispatcher learning and development. Suggested remedies include improvements in training and education (call-takers and the public), software, clinical support and patient outcome feedback.

Conclusions

Emergency Operation Centre staff identified a multitude of ways to improve the identification of patients who are at imminent risk of out-of-hospital cardiac arrest during the Emergency Medical Service call. Suggested areas for improvement include education, triage software, clinical support redesign and patient outcome feedback.

Artificial intelligence in emergency medicine. A systematic literature review

Motivation and objective: Emergency medicine is becoming a popular application area for artificial intelligence methods but remains less investigated than other healthcare branches. The need for time-sensitive decision-making on the basis of high data volumes makes the use of quantitative technologies inevitable. However, the specifics of healthcare regulations impose strict requirements for such applications. Published contributions cover separate parts of emergency medicine and use disparate data and algorithms. This study aims to systematize the relevant contributions, investigate the main obstacles to artificial intelligence applications in emergency medicine, and propose directions for further studies.

METHODS

The contributions selection process was conducted with systematic electronic databases querying and filtering with respect to established exclusion criteria. Among the 380 papers gathered from IEEE Xplore, ACM Digital Library, Springer Library, ScienceDirect, and Nature databases 116 were considered to be a part of the survey. The main features of the selected papers are the focus on emergency medicine and the use of machine learning or deep learning algorithms.

FINDINGS AND DISCUSSION

The selected papers were classified into two branches: diagnostics-specific and triage-specific. The former ones are focused on either diagnosis prediction or decision support. The latter covers such applications as mortality, outcome, admission prediction, condition severity estimation, and urgent care prediction. The observed contributions are highly specialized within a single disease or medical operation and often use privately collected retrospective data, making them incomparable. These and other issues can be addressed by creating an end-to-end solution based on human-machine interaction.

CONCLUSION

Artificial intelligence applications are finding their place in emergency medicine, while most of the corresponding studies remain isolated and lack higher generalization and more sophisticated methodology, which can be a matter of forthcoming improvements.

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.

Medical emergencies at sea: an analysis of ambulance-supported and autonomously performed operations by lifeboat crews

BACKGROUND

Very little data is available about the involvement of lifeboat crews in medical emergencies at sea. The aim of this study is to analyze the medical operations at sea performed by the Royal Netherlands Sea Rescue Institution (KNRM).

METHODS

This is a retrospective descriptive analysis of all medical operations at sea performed by the KNRM between January 2017 and January 2020. The operations were divided in three groups: with ambulance crew aboard the lifeboat, ambulance crew on land waiting for the arrival of the lifeboat, and autonomous operations (without ambulance crew involvement). The main outcome measures were circumstances, encountered medical problems, follow-up and crew departure time.

RESULTS

The KNRM performed 282 medical operations, involving 361 persons. Operations with ambulance crew aboard the lifeboat (n = 39; 42 persons) consisted mainly of persons with serious trauma or injuries; 32 persons (76.2%) were transported to a hospital. Operations with ambulance crew on land (n = 153; 188 persons) mainly consisted of situations where time was essential, such as persons who were still in the water, with risk of drowning (n = 45, 23.9%), on-going resuscitations (n = 9, 4.8%) or suicide attempts (n = 7, 3.7%). 101 persons (53,7%) were transported to a hospital. All persons involved in the autonomous operations (n = 90; 131 persons) had minor injuries. 38 persons (29%) needed additional medical care, mainly for (suspected) fractures or stitches. In 115 (40.8%) of all operations lifeboat crews did not know that there was a medical problem at the time of departure. Crew departure time in operations with ambulance crew aboard the lifeboat (13.7 min, min. 0, max. 25, SD 5.74 min.) was significantly longer than in operations with ambulance crew on land (7.7 min, min. 0, max 21, SD 4.82 min., p < 0.001).

CONCLUSION

This study provides new information about the large variety of medical emergencies at sea and the way that lifeboat and ambulance crews are involved. Crew departure time in operations with ambulance crew aboard the lifeboat was significantly longer than in operations with ambulance crew on land. This study may provide useful indications for improvement of future medical operations at sea, such as triage, because in 40.8% of operations, it was not known at the time of departure that there was a medical problem.

The National Danish Cardiac Arrest Registry for Out-of-Hospital Cardiac Arrest - A Registry in Transformation

Aim of the Database

The aim of the Danish Cardiac Arrest Registry is to monitor the quality of prehospital cardiac arrest treatment, evaluate initiatives regarding prehospital treatment of cardiac arrest, and facilitate research.

Study Population

All patients with prehospital cardiac arrest in Denmark treated by the emergency medical services in whom resuscitation or defibrillation has been attempted.

Main Variables

The Danish Cardiac Arrest Register records descriptive and qualitative variables as outlined in the “Utstein” template for reporting out-of-hospital-cardiac arrest. Main variables include whether the case was witnessed, whether the cardiac arrest was electrocardiographically monitored, the timing of cardiopulmonary resuscitation, and the timing of the first analysis of the cardiac rhythm. The outcome measures are the status of the patient at handover to the hospital, return of spontaneous circulation, and 30-day survival after event.

Database Status

The Danish Cardiac Arrest Registry was established in June 2001, and all Danish emergency medical services are reporting to the database.

Conclusion

The Danish Cardiac Arrest Registry is among the oldest Danish national clinical registries, with a high quality of clinical data and coverage. This registry provides the prerequisite for all research on out-of-hospital cardiac arrest research in Denmark and is essential for monitoring and improving the quality of care for patients suffering from out-of-hospital cardiac arrest.

Swedish dispatchers’ compliance with the American Heart Association performance goals for dispatch-assisted cardiopulmonary resuscitation and its association with survival in out-of-hospital cardiac arrest: A retrospective study

Aim

We aimed 1) to investigate how Swedish dispatchers perform during emergency calls in accordance with the American Heart Association (AHA) goals for dispatcher-assisted cardiopulmonary resuscitation (DA-CPR), 2) calculate the potential impact on 30-day survival.

Methods

This observational study includes a random sample of 1000 out-of-hospital cardiac arrest (OHCA) emergency ambulance calls during 2018 in Sweden. Voice logs were audited to evaluate dispatchers’ handling of emergency calls according to the AHA performance goals. Number of possible additional survivors was estimated assuming the timeframes of the AHA performance goals was achieved.

Results

A total of 936 cases were included. An OHCA was recognized by a dispatcher in 79% (AHA goal 75%). In recognizable OHCA, dispatchers recognized 85% (AHA goal 95%). Dispatch-directed compressions were given in 61% (AHA goal 75%). Median time to OHCA recognition was 113 s [interquartile range (IQR), 62, 204 s] (AHA goal < 60 s). The first dispatch-directed compression was performed at a median time of 240 s [IQR, 176, 332 s] (AHA goal < 90 s). If eligible patients receive dispatch-directed compressions within the AHA 90 s goal, 73 additional lives may be saved; if all cases are recognized within the AHA 60 s goal, 25 additional lives may be saved.

Conclusions

The AHA policy statement serves as a benchmark for all emergency medical dispatch centres (EMDC). Additional effort is needed at Swedish EMDC to achieve AHA goals for DA-CPR. Our study suggests that if EMDC further optimize handling of OHCA calls in accordance with AHA goals, many more lives may be saved.

Features of Emergency Medical System calls that facilitate or inhibit Emergency Medical Dispatcher recognition that a patient is in, or at imminent risk of, cardiac arrest: A systematic mixed studies review

Aim

To identify and appraise evidence relating to the features of an Emergency Medicine System call interaction that enable, or inhibit, an Emergency Medical Dispatcher’s recognition that a patient is in out-of-hospital cardiac arrest, or at imminent risk of out-of-hospital cardiac arrest.

Methods

All study designs were eligible for inclusion. Data sources included Medline, BNI, CINAHL, EMBASE, PubMed, Cochrane Database of Systematic Reviews, AMED and OpenGrey. Stakeholder resources were screened and experts in resuscitation were asked to review the studies identified. Studies were appraised using the Mixed Methods Appraisal Tool. Synthesis was completed using a segregated mixed research synthesis approach.

Results

Thirty-two studies were included in the review. Three main themes were identified: Key features of the Emergency Medical Service call interaction; Managing the Emergency Medical Service call; Emotional distress.

Conclusion

A dominant finding is the difficulty in recognising abnormal/agonal breathing during the Emergency Medical Service call. The interaction between the caller and the Emergency Medical Dispatcher is critical in the recognition of patients who suffer an out-of-hospital cardiac arrest. Emergency Medical Dispatchers adapt their approach to the Emergency Medical Service call, and regular training for Emergency Medical Dispatchers is recommended to optimise out-of-hospital cardiac arrest recognition. Further research is required with a focus on the Emergency Medical Service call interaction of patients who are alive at the time of the Emergency Medical Service call and who later deteriorate into OHCA.

PROSPERO registration: CRD42019155458.

Out of hospital cardiac arrest: Past, present, and future

Advances in resuscitation following out-of-hospital cardiac arrest (OHCA) provide an opportunity to improve public health. This review reflects on past developments, present status, and future possibilities using the science-education-implementation framework of the Utstein Formula and the clinical framework of the links in the chain of survival. With the discovery of CPR and defibrillation in the mid 20th century, resuscitation developed a scientific construct for progress. Systems of emergency community response provided operational efficiency to treat OHCA. Contemporary resuscitation involves integrated interventions in the chain of survival: early recognition, early CPR, early defibrillation, expert and timely advanced life support and hospital care, and multidimensional rehabilitation. Implementation of scientific advances is especially challenging given the unexpected nature of OHCA, the need for time-sensitive interventions, and the substantial collective of stakeholders involved in the chain of survival. Systematic measurement provides the foundation to evaluate performance and guide implementation initiatives. For many systems, telecommunicator CPR and high-performance CPR by emergency professionals are accessible, near-term programs to improve OHCA outcome. Smart technologies that activate, coordinate, and/or coach community "volunteers" to accelerate early CPR and defibrillation have conceptual promise, though robust implementation has been achieved by only a handful of systems. Longer-term strategies may leverage technology to develop a high-fidelity "life-detector" or engineer and disseminate a specialized consumer defibrillator designed to bridge care until arrival of professional response.