Dispatcher-assisted cardiopulmonary resuscitation. An evaluation of efficacy amongst elderly

Effectiveness of a dispatcher-assisted CPR using an animated image: Simulation study

INTRODUCTION

Considering the few studies evaluating bystander cardiopulmonary resuscitation (CPR) performance, we sought to analyze differences in bystander CPR performance with and without the use of our self-developed animated GIFs based on dispatcher-assisted CPR simulation.

METHODS

A total of 80 adults who had not received CPR training over the past two years participated in the study. Among them, 40 people were classified into the auditory group (receiving CPR instructions only over the phone), and the other 40 people were classified into the audiovisual group (receiving CPR instructions over the phone after receiving images on a smartphone). All participants were asked to perform adult and infant CPR for 2 min. CPR performance was recorded using two video cameras (front and side) and analyzed by two emergency physicians, whereas CPR quality was measured using Resusci Anne & Baby QCPR Mk II (Laerdal).

RESULTS

In the adult CPR study, the audiovisual group had higher performance scores for adequacy of "knee position," "hand posture," "elbow extension," and "vertical compression," as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). No significant difference in CPR quality was observed between the two groups. In the infant CPR study, audiovisual group had higher performance scores in adequacy of "compression site," "finger posture," and "vertical compression," as well as higher Standard Posture Completeness and Instruction Performance scores (p < 0.001). Regarding CPR quality, the audiovisual group had higher scores for "adequate compression rate ratio" (p = 0.047).

CONCLUSION

Audiovisual guidance using animated GIFs more effectively improved CPR Standard Posture Completeness and Instruction Performance than did traditional auditory guidance.

Evaluation of a newly developed first aid training programme adapted for older people

BACKGROUND

Older people need to acquire knowledge and skills at first aid (FA) training tailored to them. Our research aimed to evaluate an FA training programme adapted for older people. We assumed that satisfaction with FA training, as well as knowledge of FA, would be higher among older people who received training according to an adapted programme compared to those who received training according to the existing programme for the general public.

METHODS

We trained older people according to the existing FA programme for the general public and according to a new FA training programme adapted for older people. The new training program is shorter and focuses on FA contents that are more relevant for older people. We evaluated participants with a general assessment questionnaire (consisting of items regarding satisfaction, comprehensibility, length, and physical difficulty), a test on theoretical FA knowledge, and a test on practical cardiopulmonary resuscitation (CPR) knowledge. To ensure the homogeneity of the groups and to verify the impact on the results of the test of practical CPR knowledge, we also tested the participants regarding their psychophysical capabilities.

RESULTS

A total of 120 people completed the free FA training sessions. The general assessment questionnaire score of participants who were trained based on the new FA training program was 19.3 (out of 20), which was statistically significantly (p < 0.05) higher than that of those trained based on the old program (general assessment score of 17.1). Participants who were trained based on the new program scored an average of 8.6 points on the theoretical FA knowledge test, while those who were trained based on the old program scored an average of 7.1 points, which was statistically significantly (p < 0.05) lower. In both programs, the same average scores (7.5 out of 10 points) on the practical CPR knowledge test was achieved. However, participants who participated in the FA course adapted for the older people gained practical CPR knowledge in a shorter time. Older people with a greater psychophysical capacity were more successful in performing CPR, regardless of which FA training programme they received.

CONCLUSIONS

The effectiveness of FA training is greater if older people are trained in accordance with a targeted programme adapted to the psychophysical limitations of the older people.

Clinical effects of a new dispatcher-assisted basic life support training program in a metropolitan city

This study estimates the effect of a new dispatcher-assisted basic life support training program on the survival outcomes of out-of-hospital cardiac arrest (OHCA). Before-and-after intervention trials were conducted in Seoul. Patients who suffered OHCA in a private place from January 2014 to December 2017 were included. The intervention group was 3 districts; the other 22 districts were regarded as the control group. The primary outcome was survival up to hospital discharge. The difference-in-difference (DID) was calculated to evaluate changes in the survival outcomes of the 2 groups over the period. A total of 10,127 OHCA patients were included in the final analysis. OHCA patients in the intervention group were less likely to receive bystander cardiopulmonary resuscitation (57.8% vs 61.1%; P = .02) and showed lower survival outcomes (5.7% vs 6.4% for survival up to hospital discharge; P = .34 and 2.8% vs 3.7% for good neurological recovery; P = .11), but this was not statistically significant. Compared to 2014, good neurological recovery in 2017 was significantly improved in the intervention group (DID for good neurological recovery = 3.2%; 0.6-5.8). There were no statistically significant differences in return of spontaneous circulation and survival up to hospital discharge between the 2 groups (DID for survival to discharge was 1.8% [-1.7 to 5.3] and DID for return of spontaneous circulation was -2.5% [-9.8 to 4.8]). Improvement in neurological recovery was observed in the 3 districts after implementing the new dispatcher-assisted basic life support training program.

Tailoring First Aid Courses to Older Adults Participants

Relevant organizations emphasize the importance of first aid (FA) for older adults due to the increased risk of injuries and sudden illnesses in old age. Even though FA training guidelines have been developed, no program for an FA course adapted for the older adults has been formally adopted in Europe. This study’s objective is to identify older adults’ needs, beliefs, desires, advantages, and possible limitations in connection with FA. This qualitative study used semistructured interviews with 22 laypersons and retired health professionals older than 60 years old. The qualitative content analysis indicated that the major themes elicited by the older adults are motivation to participate in the FA training, older adults’ specific features as a resource or obstacle for participating in FA training, general suggestions, and content suggestions for FA training. Older adults are very differently motivated to participate in FA training due to the heterogeneity of their psychophysical abilities. They need and want to obtain additional knowledge from the field of FA and health protection for which any psychophysical limitations are not as relevant as when learning cardiopulmonary resuscitation. They want to learn how to recognize emergency situations and more about calling emergency services with the use of modern technology. In addition to cardiopulmonary resuscitation without rescue breaths, they also want to learn about topics related to the treatment of injuries. Those who had practiced FA in their work–life think that they can be a good source to transfer their knowledge to persons from their generation. While planning an FA training course, it has to be taken into consideration that older adults want a short course, adjusted to their varied psychophysical abilities. Due to the wide array of contents they want to learn, it would be reasonable to prepare a selection of different programs for short training courses.

Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition

BACKGROUND

Video call based dispatcher-assisted cardiopulmonary resuscitation (V-DACPR) has been suggested to improve the quality of bystander cardiopulmonary resuscitation. In the current system, dispatchers must convert the audio calls to video calls to provide V-DACPR. We aimed to develop new audio call-to-video call transition protocols and test its efficacy and safety compared to conventional DACPR(C-DACPR).

METHODS

This was a randomized controlled simulation trial that compared the quality of bystander chest compression that was performed under three different DACPR protocols: C-DACPR, V-DACPR with rapid transition, and V-DACPR with delayed transition. Adult volunteers excluding healthcare providers were recruited for the trial. The primary outcome of the study was the mean proportion of adequate hand positioning during chest compression.

RESULTS

Simulation results of 131 volunteers were analyzed. The mean proportion of adequate hand positioning was highest in V-DACPR with rapid transition (V-DACPR with rapid transition vs. C-DACPR: 92.7% vs. 82.4%, p = 0.03). The mean chest compression depth was deeper in both V-DACPR groups than in the C-DACPR group (V-DACPR with rapid transition vs. C-DACPR: 40.7 mm vs. 35.9 mm, p = 0.01, V-DACPR with delayed transition vs. C- DACPR: 40.9 mm vs. 35.9 mm, p = 0.01). Improvement in the proportion of adequate hand positioning was observed in the V-DACPR groups (r = 0.25, p < 0.01 for rapid transition and r = 0.19, p < 0.01 for delayed transition).

CONCLUSION

Participants in the V-DACPR groups performed higher quality chest compression with higher appropriate hand positioning and deeper compression depth compared to the C-DACPR group.

In out-of-hospital cardiac arrest, is the positioning of victims by bystanders adequate for CPR? A cohort study

OBJECTIVES

Outcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome.

DESIGN

Prospective observational cohort study.

SETTING

Metropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest.

PARTICIPANTS

Bystanders of all OHCAs occurring during a 12-month period (July 2006-July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months.

RESULTS

Positioning of victims at EMS arrival was 'supine on firm surface' in 64 cases (32.0%), 'recovery position (RP)' in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when 'supine position' had been applied, 13.5% with 'RP' and 6.1% with 'other positions unsuitable for CCs'; a statistically significant association could not be shown (p=0.740, Fisher's exact test). However, after 'effective CCs' favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02).

CONCLUSION

In OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.

The Effectiveness of a New Dispatcher-Assisted Basic Life Support Training Program on Quality in Cardiopulmonary Resuscitation Performance During Training and Willingness to Perform Bystander Cardiopulmonary Resuscitation: A Cluster Randomized Controlled Study

INTRODUCTION

A new dispatcher-assisted basic life support training program, called "Home Education and Resuscitation Outcome Study (HEROS)" was developed with a goal to provide high-quality dispatcher-assisted cardiopulmonary resuscitation (CPR) training, with a focus on untrained home bystanders. This study aimed to determine whether the HEROS program is associated with improved quality in CPR performance during training and willingness to provide bystander CPR compared with other basic life support programs without dispatcher-assisted CPR (non-HEROS).

METHODS

This clustered randomized trial was conducted in 3 district health centers in Seoul. Intervention group was trained with the HEROS program and control group was trained with non-HEROS program. The primary outcome was overall CPR quality, measured as total CPR score. Secondary outcomes were other CPR quality parameters including average compression depth and rate, percentages of adequate depth, and acceptable release. Tertiary outcomes were posttraining survey results. Difference in difference analysis was performed to analyze the outcomes.

RESULTS

Among total 1929 trainees, 907 (47.0%) were trained with HEROS program. Compared with the non-HEROS group, the HEROS group showed higher-quality CPR performances and better maintenance of their CPR quality throughout the course (total scores of 84% vs. 80% for first session and 72% vs. 67% for last session; difference in difference of 12.2 vs. 13.2). Other individual CPR parameters also showed significantly higher quality in the HEROS group. The posttraining survey showed that both groups were highly willing to perform bystander CPR (91.4% in the HEROS vs. 92.3% in the non-HEROS) with only 3.4% of respondents in the HEROS group were not willing to volunteer compared with 6.2% in the non-HEROS group (P < 0.01).

CONCLUSIONS

The HEROS training program helped trainees perform high-quality CPR throughout the course and enhanced their willingness to provide bystander CPR.

Improving emergency call detection of Out-of-Hospital Cardiac Arrests in the Greater Paris area: Efficiency of a global system with a new method of detection

AIM

The detection of cardiac arrests by dispatchers allows telephone-assisted cardiopulmonary resuscitation (t-CPR) and improves Out-of-Hospital Cardiac Arrest (OHCA) survival. To enhance the OHCA detection rate, in 2012, the Paris Fire Brigade dispatch center created an original technique called "Hand On Belly" (HoB). The new algorithm that resulted has become a central point in a broader program for dispatch-assisted cardiac arrests.

METHODS

This is a repeated cross-sectional study with retrospective data of four 15-day call samples recorded from 2012 to 2018. We included all calls from OHCAs cared for by Basic Life Support (BLS) teams and excluded calls where the dispatcher was not in contact directly with a witness. The primary endpoint was the successful detection of an OHCA by the dispatcher; the secondary endpoints were successful t-CPR and measurements of the different time intervals related to the call. Logistic regressions were performed to assess parameters associated with detecting OHCAs and initiating t-CPR.

RESULTS

From 2012 to 2018, among the detectable OCHAs, the proportion correctly identified increased from 54% to 93%; the rate of t-CPRs from 51% to 84%. OHCA detection and t-CPR initiation were both associated with HoB breathing assessments (adjustedOR: 89, 95%CI: 31-299, and adjustedOR: 11.2, 95%CI: 1.4-149, respectively). Over the study period, the times to answering calls and the time to sending BLS teams were shorter than those recommended by international guidelines; however, the times to OHCA recognition and starting t-CPR delivery were longer.

CONCLUSIONS

The HoB effectively facilitated OHCA detection in our system, which has achieved very high performance levels.

Effects of dispatcher-initiated telephone cardiopulmonary resuscitation after out-of-hospital cardiac arrest: A nationwide, population-based, cohort study

AIM

This study aimed to investigate the effects of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) in Japan using a nationwide population-based registry.

METHODS

Adult Japanese patients with out-of-hospital cardiac arrest (OHCA; n = 582,483, age ≥18 years) were selected from a nationwide Utstein-style database (2010-2016) and divided into 3 groups: no bystander CPR (NCPR) before emergency medical service arrival (n = 448,606), bystander-initiated CPR (BCPR) performed without assistance (n = 46,964), and TCPR (n = 86,913). The primary outcome was a favourable neurological outcome 1 month after OHCA.

RESULTS

After adjusting for potential confounders, and relative to the NCPR group, significantly better 1-month neurological outcomes were observed in the BCPR group (odds ratio: 2.25, 95% confidence interval: 2.15-2.36; P < 0.001) and in the TCPR group (odds ratio: 1.30, 95% confidence interval: 1.24-1.36; P < 0.001). The collapse-to-CPR time was independently associated with the 1-month outcomes, with a rate of <1% for 1-month favourable neurological outcomes if CPR was initiated >5 min after the collapse.

CONCLUSION

Patients who received TCPR had significantly better outcomes than those who did not receive CPR. However, the TCPR outcomes were less favourable than those in the BCPR group. Better protocol development and enhanced education are needed to improve dispatcher instructions in Japan, which may help lessen the gap between the BCPR and TCPR outcomes and further improve the outcomes after OHCA.

Comparison of Cardiopulmonary Resuscitation Quality Between Standard Versus Telephone-Basic Life Support Training Program in Middle-Aged and Elderly Housewives: A Randomized Simulation Study

INTRODUCTION

For cardiac arrests witnessed at home, the witness is usually a middle-aged or older housewife. We compared the quality of cardiopulmonary resuscitation (CPR) performance of bystanders trained with the newly developed telephone-basic life support (T-BLS) program and those trained with standard BLS (S-BLS) training programs.

METHODS

Twenty-four middle-aged and older housewives without previous CPR education were enrolled and randomized into two groups of BLS training programs. The T-BLS training program included concepts and current instruction protocols for telephone-assisted CPR, whereas the S-BLS training program provided training for BLS. After each training course, the participants simulated CPR and were assisted by a dispatcher via telephone. Cardiopulmonary resuscitation quality was measured and recorded using a mannequin simulator. The primary outcome was total no-flow time (>1.5 seconds without chest compression) during simulation.

RESULTS

Among 24 participants, two (8.3%) who experienced mechanical failure of simulation mannequin and one (4.2%) who violated simulation protocols were excluded at initial simulation, and two (8.3%) refused follow-up after 6 months. The median (interquartile range) total no-flow time during initial simulation was 79.6 (66.4-96.9) seconds for the T-BLS training group and 147.6 (122.5-184.0) seconds for the S-BLS training group (P < 0.01). Median cumulative interruption time and median number of interruption events during BLS at initial simulation and 6-month follow-up simulation were significantly shorter in the T-BLS than in the S-BLS group (1.0 vs. 9.5, P < 0.01, and 1.0 vs. 10.5, P = 0.02, respectively).

CONCLUSIONS

Participants trained with the T-BLS training program showed shorter no-flow time and fewer interruptions during bystander CPR simulation assisted by a dispatcher.

Skills among young and elderly laypersons during simulated dispatcher assisted CPR and after CPR training

BACKGROUND

Dispatcher assisted cardiopulmonary resuscitation (DA-CPR) increase the rate of bystander CPR. The aim of the study was to compare the performance of DA-CPR and attainable skills following CPR training between young and elderly laypersons.

METHODS

Volunteer laypersons (young: 18-40 years; elderly: > 65 years) participated. Single rescuer CPR was performed in a simulated DA-CPR cardiac arrest scenario and after CPR training. Data were obtained from a manikin and from video recordings. The primary endpoint was chest compression depth.

RESULTS

Overall, 56 young (median age: 26, years since last CPR training: 6) and 58 elderly (median age: 72, years since last CPR training: 26.5) participated. Young laypersons performed deeper (mean (SD): 56 (14) mm vs. 39 (19) mm, P < 0.001) and faster (median (25th-75th percentile): 107 (97-112) per min vs. 84 (74-107) per min, P < 0.001) chest compressions compared to elderly. Young laypersons had shorter time to first compression (mean (SD): 71 (11) seconds vs. 104 (38) seconds, P < 0.001) and less hands-off time (median (25th-75th percentile): 0 (0-1) seconds vs. 5 (2-10) seconds, P < 0.001) than elderly. After CPR training chest compressions were performed with a depth (mean (SD): 64 (8) mm vs. 50 (14) mm, P < 0.001) and rate (mean (SD): 111 (11) per min vs. 93 (18) per min, P < 0.001) for young and elderly laypersons respectively.

CONCLUSION

Despite long CPR retention time for both groups, elderly laypersons had longer retention time, and performed inadequate DA-CPR compared to young laypersons. Following CPR training the attainable CPR level was of acceptable quality for both young and elderly laypersons.

Easy-to-learn cardiopulmonary resuscitation training programme: a randomised controlled trial on laypeople's resuscitation performance

INTRODUCTION

Simplifying the learning of cardiopulmonary resuscitation (CPR) is advocated to improve skill acquisition and retention. A simplified CPR training programme focusing on continuous chest compression, with a simple landmark tracing technique, was introduced to laypeople. The study aimed to examine the effectiveness of the simplified CPR training in improving lay rescuers' CPR performance as compared to standard CPR.

METHODS

A total of 85 laypeople (aged 21-60 years) were recruited and randomly assigned to undertake either a two-hour simplified or standard CPR training session. They were tested two months after the training on a simulated cardiac arrest scenario. Participants' performance on the sequence of CPR steps was observed and evaluated using a validated CPR algorithm checklist. The quality of chest compression and ventilation was assessed from the recording manikins.

RESULTS

The simplified CPR group performed significantly better on the CPR algorithm when compared to the standard CPR group (p < 0.01). No significant difference was found between the groups in time taken to initiate CPR. However, a significantly higher number of compressions and proportion of adequate compressions was demonstrated by the simplified group than the standard group (p < 0.01). Hands-off time was significantly shorter in the simplified CPR group than in the standard CPR group (p < 0.001).

CONCLUSION

Simplifying the learning of CPR by focusing on continuous chest compressions, with simple hand placement for chest compression, could lead to better acquisition and retention of CPR algorithms, and better quality of chest compressions than standard CPR.

Location of cardiac arrest and impact of pre-arrest chronic disease and medication use on survival

INTRODUCTION

Cardiac arrest in a private location is associated with a higher mortality when compared to public location. Past studies have not accounted for pre-arrest factors such as chronic disease and medication.

AIM

To investigate whether the association between cardiac arrest in a private location and a higher mortality can be explained by differences in chronic diseases and medication.

METHODS

We identified 27,771 out-of-hospital cardiac arrest patients ≥18 years old from the Danish Cardiac Arrest Registry (2001-2012). Using National Registries, we identified pre-arrest chronic disease and medication. To investigate the importance of cardiac arrest related factors and chronic disease and medication use we performed adjusted Cox regression analyses during day 0-7 and day 8-365 following cardiac arrest to calculate hazard ratios (HR) for death.

RESULTS

Day 0-7: Un-adjusted HR for death day 0-7 was 1.21 (95%CI:1.18-1.25) in private compared to public location. When including cardiac arrest related factors HR for death was 1.09 (95%CI:1.06-1.12). Adding chronic disease and medication to the analysis changed HR for death to 1.08 (95%CI:1.05-1.12). 8-365 day: The un-adjusted HR for death day 8-365 was 1.70 (95% CI: 1.43-2.02) in private compared to public location. When including cardiac arrest related factors the HR decreased to 1.39 (95% CI: 1.14-1.68). Adding chronic disease and medication to the analysis changed HR for death to 1.27 (95% CI:1.04-1.54).

CONCLUSION

The higher mortality following cardiac arrest in a private location is partly explained by a higher prevalence of chronic disease and medication use in patients surviving until day 8.

Are two or four hands needed for elderly female bystanders to achieve the required chest compression depth during dispatcher-assisted CPR: a randomized controlled trial

Background

Rescuers are often unable to achieve the recommended 5–6 cm CC depth. The physical limitations of elderly bystanders may affect the quality of CC; thus, we investigated new strategies to improve CC performance.

Methods

We performed a randomized controlled trial in December 2013. Sixty-eight lay rescuers aged 50–75 were randomized to intervention or control pairs (males and females separately). Each pair performed 8 min of DA-CPR on a manikin connected to a PC. Each participant in every pair took turns performing CCs in cycles of 2 min and switched as advised by the dispatcher. In the middle of every 2-min cycle, the dispatcher asked the participants of the intervention group to perform the Andrew’s manoeuvre (to push on the shoulders of the person while he/she performed CCs to achieve deeper CC). Data on the quality of the CCs were analysed for each participant and pair.

Results

The CC depth in the intervention group increased by 6.4 mm (p = 0.002) compared to the control group (54.2 vs. 47.8 mm) due to a significant difference in the female group. The CC depth in the female intervention and control groups was 51.5 and 44.9 mm.

Discussion

The largest group of out-of-hospital cardiac arrest occurred in males over the age of 60 at home, and accordingly, the most likely witness, if any, is the spouse or family member, most frequently an older woman. There is a growing body of evidence that female rescuers are frequently unable to achieve sufficient CC depth compared to male rescuers. In some instances, the adequate depth of the CCs could only be reached using four hands, with the second pair of hands placed on the shoulders of the rescuer performing CPR. 

Conclusion

Andrew’s manoeuvre (four-hands CC) during the simulated DA-CPR significantly improved the performance of elderly female rescuers and helped them to achieve the recommended CC depth.

Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest

BACKGROUND

Cardiopulmonary resuscitation (CPR) performed by bystanders is associated with increased survival rates among persons with out-of-hospital cardiac arrest. We investigated whether rates of bystander-initiated CPR could be increased with the use of a mobile-phone positioning system that could instantly locate mobile-phone users and dispatch lay volunteers who were trained in CPR to a patient nearby with out-of-hospital cardiac arrest.

METHODS

We conducted a blinded, randomized, controlled trial in Stockholm from April 2012 through December 2013. A mobile-phone positioning system that was activated when ambulance, fire, and police services were dispatched was used to locate trained volunteers who were within 500 m of patients with out-of-hospital cardiac arrest; volunteers were then dispatched to the patients (the intervention group) or not dispatched to them (the control group). The primary outcome was bystander-initiated CPR before the arrival of ambulance, fire, and police services.

RESULTS

A total of 5989 lay volunteers who were trained in CPR were recruited initially, and overall 9828 were recruited during the study. The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests: 46% (306 patients) in the intervention group and 54% (361 patients) in the control group. The rate of bystander-initiated CPR was 62% (188 of 305 patients) in the intervention group and 48% (172 of 360 patients) in the control group (absolute difference for intervention vs. control, 14 percentage points; 95% confidence interval, 6 to 21; P<0.001).

CONCLUSIONS

A mobile-phone positioning system to dispatch lay volunteers who were trained in CPR was associated with significantly increased rates of bystander-initiated CPR among persons with out-of-hospital cardiac arrest. (Funded by the Swedish Heart-Lung Foundation and Stockholm County; ClinicalTrials.gov number, NCT01789554.).

Understanding and improving low bystander CPR rates: a systematic review of the literature

Objectives:

Cardiopulmonary resuscitation (CPR) is a crucial yet weak link in the chain of survival for out-of-hospital cardiac arrest. We sought to understand the determinants of bystander CPR and the factors associated with successful training.

Methods:

For this systematic review, we searched 11 electronic databases, 1 trial registry and 9 scientific websites. We performed hand searches and contacted 6 content experts. We reviewed without restriction all communications pertaining to who should learn CPR, what should be taught, when to repeat training, where to give CPR instructions and why people lack the motivation to learn and perform CPR. We used standardized forms to review papers for inclusion, quality and data extraction. We grouped publications by category and classified recommendations using a standardized classification system that was based on level of evidence.

Results:

We reviewed 2409 articles and selected 411 for complete evaluation. We included 252 of the 411 papers in this systematic review. Differences in their study design precluded a meta-analysis. We classified 22 recommendations; those with the highest scores were 1) 9-1-1 dispatch-assisted CPR instructions, 2) teaching CPR to family members of cardiac patients, 3) Braslow's self-training video, 4) maximizing time spent using manikins and 5) teaching the concepts of ambiguity and diffusion of responsibility. Recommendations not supported by evidence include mass training events, pulse taking prior to CPR by laymen and CPR using chest compressions alone.

Conclusion:

We evaluated and classified the potential impact of interventions that have been proposed to improve bystander CPR rates. Our results may help communities design interventions to improve their bystander CPR rates.

Changes to DA-CPR instructions: can we reduce time to first compression and improve quality of bystander CPR?

INTRODUCTION

Dispatcher-assisted CPR (DA-CPR) can increase rates of bystander CPR, survival, and quality of life following cardiac arrest. Dispatcher protocols designed to improve rapid recognition of arrest and coach CPR may increase survival by (1) reducing preventable time delays to start of chest compressions and (2) improving the quality of bystander CPR.

METHODS

We conducted a randomized controlled trial comparing a simplified DA CPR script to a conventional DA CPR script in a manikin cardiac arrest simulation with lay participants. The primary outcomes measured were the time interval from call receipt to the first chest compression and the core metrics of chest compression (depth, rate, release, and compression fraction). CPR was measured using a recording manikin for the first 3 min of participant CPR.

RESULTS

Of the 75 participants, 39 were randomized to the simplified instructions and 36 were randomized to the conventional instructions. The interval from call receipt to first compression was 99 s using the simplified script and 124 s using the conventional script for a difference of 24s (p<0.01). Although hand position was judged to be correct more often in the conventional instruction group (88% versus 63%, p<0.01), compression depth was an average 7 mm deeper among those receiving the simplified CPR script (32 mm versus 25 mm, p<0.05). No statistically significant differences were detected between the two instruction groups for compression rate, complete release, number of hands-off periods, or compression fraction.

DISCUSSION

Simplified DA-CPR instructions to lay callers in simulated cardiac arrest settings resulted in significant reductions in time to first compression and improvements in compression depth. These results suggest an important opportunity to improve DA CPR instructions to reduce delays and improve CPR quality.

Survey of a Protocol to Increase Appropriate Implementation of Dispatcher-Assisted Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest

Background—

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) attempts to improve the management of out-of-hospital cardiac arrest by laypersons who are unable to recognize cardiac arrest and are unfamiliar with CPR. Therefore, we investigated the sensitivity and specificity of our new DA-CPR protocol for achieving implementation of bystander CPR in out-of-hospital cardiac arrest victims not already receiving bystander CPR.

Methods and Results—

Since 2007, we have applied a new DA-CPR protocol that uses supplementary key words. Fire departments prospectively collected baseline data on DA-CPR from January 2009 to December 2011. DA-CPR was attempted in 2747 patients; of these, 417 (15.2%) did not experience cardiac arrest. The sensitivity and specificity of the 2007 protocol versus estimated values of the previous standard protocol were 72.9% versus 50.3% and 99.6% versus 99.8%, respectively. We identified key words that may be useful for detecting out-of-hospital cardiac arrest. Multiple logistic regression analysis revealed that the occurrence of cardiac arrest after an emergency call (odds ratio, 16.85) and placing an emergency call away from the scene of the arrest (odds ratio, 11.04) were potentially associated with failure to provide DA-CPR. Furthermore, at-home cardiac arrest (odds ratio, 1.61) and family members as bystanders (odds ratio, 1.55) were associated with bystander noncompliance with DA-CPR. No complications were reported in the 417 patients who received DA-CPR but did not have cardiac arrest.

Conclusions—

Our 2007 protocol is safe and highly specific and may be more sensitive than the standard protocol. Understanding the factors associated with failure of bystanders to provide DA-CPR and implementing public education are necessary to increase the benefit of DA-CPR.

Basic life support training for single rescuers efficiently augments their willingness to make early emergency calls with no available help: a cross-over questionnaire survey

BACKGROUND

The aim of this study was to investigate effects of basic life support (BLS) training on willingness of single rescuers to make emergency calls during out-of-hospital cardiac arrests (OHCAs) with no available help from others.

METHODS

A cross-over questionnaire survey was conducted with two questionnaires. Questionnaires were administered before and after two BLS courses in fire departments. One questionnaire included two scenarios which simulate OHCAs occurring in situations where help from other rescuers is available (Scenario-M) and not available (Scenario-S). The conventional BLS course was designed for multiple rescuers (Course-M), and the other was designed for single rescuers (Course-S).

RESULTS

Of 2,312 respondents, 2,218 (95.9%) answered all questions and were included in the analysis. Although both Course-M and Course-S significantly augmented willingness to make early emergency calls not only in Scenario-M but also in Scenario-S, the willingness for Scenario-M after training course was significantly higher in respondents of Course-S than in those of Course-M (odds ratio 1.706, 95% confidential interval 1.301-2.237). Multiple logistic regression analysis for Scenario-M disclosed that post training (adjusted odds ratio 11.6, 95% confidence interval 7.84-18.0), age (0.99, 0.98-0.99), male gender (1.77, 1.39-2.24), prior BLS experience of at least three times (1.46, 1.25-2.59), and time passed since most recent training during 3 years or less (1.80, 1.25-2.59) were independently associated with willingness to make early emergency calls and that type of BLS course was not independently associated with willingness. Therefore, both Course-M and Course-S similarly augmented willingness in Scenario-M. However, in multiple logistic regression analyses for Scenario-S, Course-S was independently associated with willingness to make early emergency calls in Scenario-S (1.26, 1.00-1.57), indicating that Course-S more efficiently augmented willingness. Moreover, post training (2.30, 1.86-2.83) and male gender (1.26, 1.02-1.57) were other independent factors associated with willingness in Scenario-S.

CONCLUSIONS

BLS courses designed for single rescuers with no help available from others are likely to augment willingness to make early emergency calls more efficiently than conventional BLS courses designed for multiple rescuers.

"Push as hard as you can" instruction for telephone cardiopulmonary resuscitation: a randomized simulation study

BACKGROUND

The medical priority dispatch system (MPDS®) assists lay rescuers in protocol-driven telephone-assisted cardiopulmonary resuscitation (CPR).

OBJECTIVE

Our aim was to clarify which CPR instruction leads to sufficient compression depth.

METHODS

This was an investigator-blinded, randomized, parallel group, simulation study to investigate 10 min of chest compressions after the instruction "push down firmly 5 cm" vs. "push as hard as you can." Primary outcome was defined as compression depth. Secondary outcomes were participants exertion measured by Borg scale, provider's systolic and diastolic blood pressure, and quality values measured by the skill-reporting program of the Resusci(®) Anne Simulator manikin. For the analysis of the primary outcome, we used a linear random intercept model to allow for the repeated measurements with the intervention as a covariate.

RESULTS

Thirteen participants were allocated to control and intervention. One participant (intervention) dropped out after min 7 because of exhaustion. Primary outcome showed a mean compression depth of 44.1 mm, with an inter-individual standard deviation (SDb) of 13.0 mm and an intra-individual standard deviation (SDw) of 6.7 mm for the control group vs. 46.1 mm and a SDb of 9.0 mm and SDw of 10.3 mm for the intervention group (difference: 1.9; 95% confidence interval -6.9 to 10.8; p = 0.66). Secondary outcomes showed no difference for exhaustion and CPR-quality values.

CONCLUSIONS

There is no difference in compression depth, quality of CPR, or physical strain on lay rescuers using the initial instruction "push as hard as you can" vs. the standard MPDS(®) instruction "push down firmly 5 cm."

Quality of CPR performed by trained bystanders with optimized pre-arrival instructions

OBJECTIVE

Telephone-CPR (T-CPR) can increase initiation of bystander CPR. We wanted to study if quality oriented continuous T-CPR would improve CPR performance vs. standard T-CPR.

METHOD

Ninety-five trained rescuers aged 22-69 were randomized to standard T-CPR or experimental continuous T-CPR (comprises continuous instructions, questions and encouragement). They were instructed to perform 10 min of chest compressions-only on a manikin, which recorded CPR performance in a small, confined kitchen. Three video-cameras captured algorithm time data, CPR technique and communication. Demography and training experience were captured during debriefing.

RESULTS

Participants receiving continuous T-CPR delivered significantly more chest compressions (median 1000 vs. 870 compressions, p=0.014) and compressed more frequently to a compression rate between 90 and 120 min(-1) (median 87% vs. 60% of compressions, p<0.001), compared to those receiving standard T-CPR. This also resulted in less time without compressions after CPR had started (median 12s vs. 64 s, p<0.001), but longer time interval from initiating contact with dispatcher to first chest compression (median 144 s vs. 84 s, p<0.001). There was no difference in chest compression depth (mean 47 mm vs. 48 mm, p = 0.90) or in demography, education and previous CPR training between the groups.

CONCLUSION

In our simulated scenario with CPR trained lay rescuers, experimental continuous T-CPR gave better chest compression rate and less hands-off time during CPR, but resulted in delayed time to first chest compression compared to standard T-CPR instructions.

Effects of repetitive or intensified instructions in telephone assisted, bystander cardiopulmonary resuscitation: an investigator-blinded, 4-armed, randomized, factorial simulation trial

BACKGROUND

Compression depth is frequently suboptimal in cardiopulmonary resuscitation (CPR). We investigated effects of intensified wording and/or repetitive target depth instructions on compression depth in telephone-assisted, protocol driven, bystander CPR on a simulation manikin.

METHODS

Thirty-two volunteers performed 10 min of compression only-CPR in a prospective, investigator-blinded, 4-armed, factorial setting. Participants were randomized either to standard wording ("push down firmly 5 cm"), intensified wording ("it is very important to push down 5 cm every time") or standard or intensified wording repeated every 20s. Three dispatchers were randomized to give these instructions. Primary outcome was relative compression depth (absolute compression depth minus leaning depth). Secondary outcomes were absolute distance, hands-off times as well as BORG-scale and nine-hole peg test (NHPT), pulse rate and blood pressure to reflect physical exertion. We applied a random effects linear regression model.

RESULTS

Relative compression depth was 35 ± 10 mm (standard) versus 31 ± 11 mm (intensified wording) versus 25 ± 8 mm (repeated standard) and 31 ± 14 mm (repeated intensified wording). Adjusted for design, body mass index and female sex, intensified wording and repetition led to decreased compression depth of 13 (95%CI -25 to -1) mm (p=0.04) and 9 (95%CI -21 to 3) mm (p=0.13), respectively. Secondary outcomes regarding intensified wording showed significant differences for absolute distance (43 ± 2 versus 20 (95%CI 3-37) mm; p=0.01) and hands-off times (60 ± 40 versus 157 (95%CI 63-251) s; p=0.04).

CONCLUSION

In protocol driven, telephone-assisted, bystander CPR, intensified wording and/or repetitive target depth instruction will not improve compression depth compared to the standard instruction.

Time delays and capability of elderly to activate speaker function for continuous telephone CPR

BACKGROUND

Telephone-CPR (T-CPR) can increase rate of bystander CPR as well as CPR quality. Instructions for T-CPR were developed when most callers used a land line. Telephones today are often wireless and can be brought to the patient. They often have speaker function which further allows the rescuer to receive instructions while performing CPR.We wanted to measure adult lay people's ability to activate the speaker function on their own mobile phone.

METHODS

Elderly lay people, previously trained in CPR, were contacted by telephone. Participants with speaker function experience were asked to activate this without further instructions, while participants with no experience were given instructions on how to activate it. Participants were divided in three groups; Group 1: Can activate the speaker function without instruction, Group 2: Can activate the speaker function with instruction, and Group 3: Unable to activate the speaker function. Time to activation for group 1 and 2 was compared using Mann-Whitney U-test.

RESULTS

Seventy-two elderly lay people, mean age 68 ± 6 years participated in the study. Thirty-five (35)% of the participants were able to activate the speaker function without instructions, 29% with instructions and 36% were unable to activate the speaker function. The median time to activate the speaker function was 8s and 93s, with and without instructions, respectively (p < 0.01).

CONCLUSION

One-third of the elderly could activate speaker function quickly, and two-third either used a long time or could not activate the function.

Efficacy of metronome sound guidance via a phone speaker during dispatcher-assisted compression-only cardiopulmonary resuscitation by an untrained layperson: a randomised controlled simulation study using a manikin

AIM

Untrained laypersons should perform compression-only cardiopulmonary resuscitation (COCPR) under a dispatcher's guidance, but the quality of the chest compressions may be suboptimal. We hypothesised that providing metronome sounds via a phone speaker may improve the quality of chest compressions during dispatcher-assisted COCPR (DA-COCPR).

METHODS

Untrained laypersons were allocated to either the metronome sound-guided group (MG), who performed DA-COCPR with metronome sounds (110 ticks/min), or the control group (CG), who performed conventional DA-COCPR. The participants of each group performed DA-COCPR for 4 min using a manikin with Skill-Reporter, and the data regarding chest compression quality were collected.

RESULTS

The data from 33 cases of DA-COCPR in the MG and 34 cases in the CG were compared. The MG showed a faster compression rate than the CG (111.9 vs 96.7/min; p=0.018). A significantly higher proportion of subjects in the MG performed the DA-COCPR with an accurate chest compression rate (100-120/min) compared with the subjects in the CG (32/33 (97.0%) vs 5/34 (14.7%); p<0.0001). The mean compression depth was not different between the MG and the CG (45.9 vs 46.8 mm; p=0.692). However, a higher proportion of subjects in the MG performed shallow compressions (compression depth <38 mm) compared with subjects in the CG (median % was 69.2 vs 15.7; p=0.035).

CONCLUSIONS

Metronome sound guidance during DA-COCPR for the untrained bystanders improved the chest compression rates, but was associated more with shallow compressions than the conventional DA-COCPR in a manikin model.

A randomized trial on elderly laypersons' CPR performance in a realistic cardiac arrest simulation

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) is important for survival after cardiac arrest. We hypothesized that elderly laypersons would perform CPR poorer in a realistic cardiac arrest simulation, compared to a traditional test.

METHODS

Sixty-four lay rescuers aged 50-75 were randomized to realistic or traditional test, both with ten minutes of telephone assisted CPR. Realistic simulation started suddenly without warning, leaving the test subject alone in a confined and noisy apartment. Traditional test was conducted in a spacious and calm classroom with a researcher present. CPR performance was recorded with a manikin with human like chest properties. Heart rate and self-reported exhaustion were registered.

RESULTS

CPR quality was not different in the two groups: compression depth, 43 mm ± 7 versus 43 ± 4, P = 0.72; compressions rate, 97 min(-1) ± 11 versus 93 ± 15, P = 0.26; ventilation rate, 2.4 min(-1) ± 1.7 versus 2.8 ± 1.1, P = 0.35; and hands-off time 273 s ± 50 versus 270 ± 66, P = 0.82; in realistic (n = 31) and traditional (n = 33) groups, respectively. No fatigue was evident in the repeated measures analysis of variance. Work load was not different between the groups; attained percentage of age predicted maximum heart rate, 73% ± 9 and 76 ± 11, P = 0.37, reported exhaustion 43 ± 21 (scale: 0 to 100) and 37 ± 19, P = 0.24.

CONCLUSIONS

Elderly lay people are capable of performing chest compressions with acceptable quality for ten minutes in a realistic cardiac arrest simulation. Ventilation quality and hands-off time were not adequate in either group.

Time to first compression using Medical Priority Dispatch System compression-first dispatcher-assisted cardiopulmonary resuscitation protocols

INTRODUCTION

Without bystander cardiopulmonary resuscitation (CPR), cardiac arrest survival decreases 7%-10% for every minute of delay until defibrillation. Dispatcher-assisted CPR (D-CPR) has been shown to increase the rates of bystander CPR and cardiac arrest survival. Other reports suggest that the most critical component of bystander CPR is chest compressions with minimal interruption. Beginning with version 11.2 of the Medical Priority Dispatch System (MPDS) protocols, instructions for mouth-to-mouth ventilation (MTMV) and pulse check were removed and a compression-first pathway was introduced to facilitate rapid delivery of compressions. Additionally, unconscious choking and third-trimester pregnancy decision-making criteria were added in versions 11.3 and 12.0, respectively. However, the effects of these changes on time to first compression (TTFC) have not been evaluated.

OBJECTIVE

We sought to quantify the TTFC of MPDS versions 11.2, 11.3, and 12.0 for all calls identified as cardiac arrest on call intake that did not require MTMV instruction.

METHODS

Audio recordings of all D-CPR events for October 2005 through May 2010 were analyzed for TTFC. Differences in TTFC across versions were compared using the Kruskal-Wallis test.

RESULTS

A total of 778 cases received D-CPR. Of these, 259 were excluded because they met criteria for MTMV (pediatric patients, allergic reaction, etc.), were missing data, or were not initially identified as cardiac arrest. Of the remaining 519 calls, the mean TTFC was 240 seconds, with no significant variation across the MPDS versions (p = 0.08).

CONCLUSIONS

Following the removal of instructions for pulse check and MTMV, as well as other minor changes in the MPDS protocols, we found the overall TTFC to be 240 seconds with little variation across the three versions evaluated. This represents an improvement in TTFC compared with reports of an earlier version of MPDS that included pulse checks and MTMV instructions (315 seconds). However, the MPDS TTFC does not compare favorably with reports of older, non-MPDS protocols that included pulse checks and MTMV. Efforts should continue to focus on improving this key, and modifiable, determinant of cardiac arrest survival.

Video analysis of dispatcher-rescuer teamwork-Effects on CPR technique and performance

OBJECTIVE

We wanted to study the effect of continuous dispatcher communication on CPR technique and performance during 10min of simulated cardiac arrest.

METHOD

We reviewed video recordings and manikin data from 30 CPR trained lay people who where left alone in a simulated cardiac arrest situation with a manikin in a home-like environment (in a small, confined kitchen with the disturbing noise of a radio). CPR was performed for 10min with continuous telephone instructions via speaker function from a dispatcher. The dispatcher was blinded for CPR performance and video. Dispatcher communication, compression technique and ventilation technique was scored as accomplished or failed in the 1st and 10th minute.

RESULTS

29/30 rescuers were able to hear instructions, answer questions from the dispatcher and perform CPR in parallel. Rescuer position beside manikin was initially correct for 13/30, improving to 21/30 (p=0.008). Compression technique was adequate for the whole episode, with an insignificant trend for improvement; 29 to 30/30 using straight arms, 28 to 30/30 in a vertical position over chest and 24 to 27/30 counting loudly. 17/29 placed their hands between the nipples initially, improving to 24/29 (p=0.065). Mean compression rate improved from 84 to 101min(-1) (p<0.001), and compression depth maintained adequate (43 to 42mm). Initially, 17/29 used chin-lift manoeuvre, 14/30 used head-tilt and 19/29 used nose pinch to manage open airways, compared to 18, 20 and 22/29 (ns) in the 10th minute, respectively. Successful delivery of ventilation improved from 13/30 to 23/30 (p=0.006).

CONCLUSION

Bystander and dispatcher can communicate successfully during ongoing CPR using a telephone with speaker function. CPR technique and quality improved or did not change over 10min with continuous dispatcher assistance. These results suggest a potential for improved bystander CPR using rescuer-dispatcher teamwork.

Video calls for dispatcher-assisted cardiopulmonary resuscitation can improve the confidence of lay rescuers – surveys after simulated cardiac arrest

Many mobile phones allow two-way video communication, which permits callers to hear and see each other. If used during medical emergencies, bystanders can receive supervision and guidance from medical staff based on visual information. We investigated whether video calls from mobile phones could improve the confidence of lay rescuers. High school students ( n = 180) were randomly assigned in groups of three to communicate via video calls or via ordinary mobile phone calls. They received realtime guidance from experienced nurse dispatchers at an emergency medical dispatch centre during 10-min scenarios of simulated cardiac arrest. Each student answered a questionnaire to assess understanding, confidence and usefulness of the technology. The mean age was 17.3 years in the video group and 17.9 years in the audio group. There were 27% male participants in the video group and 34% male participants in the audio group. Seventy-three percent of the students in the video group and 71% in the audio group reported previous cardiopulmonary resuscitation training. Rescuers who had not used video phones had a greater tendency to comment on immature video call technology, while some who had used video phones complained about poor sound quality during video calls. The majority of rescuers in both groups believed that video calls were superior to audio calls during medical emergencies, and this proportion was significantly higher in the video group ( P = 0.0002). We found that visual contact and supervision through video calls improved rescuers' confidence in stressful emergencies.

Dispatcher-assisted telephone cardiopulmonary resuscitation using a French-language compression-only protocol in volunteers with or without prior life support training: A randomized trial

OBJECTIVES

Due to the recent interest in hands-only protocols for dispatcher-assisted cardiopulmonary resuscitation (CPR) and the lack of any validated algorithms in French, our primary objective was to evaluate a new French-language protocol in terms of its efficacy to help previously untrained volunteers in performing basic life support efforts of appropriate quality, and secondarily to investigate its potential utility in subjects with previous training.

METHODS

Untrained volunteers were recruited among adults in a public movie centre and previously trained volunteers among undergraduate nursing students. Participants were randomly assigned to 'phone CPR' versus 'no phone CPR' by drawing sets of envelopes. Primary outcome measures were the results of the Cardiff evaluation test; the secondary measures were global scoring of a complete 5min period of CPR, in a manikin model of cardiac arrest.

RESULTS

Out of 146 volunteers assessed for eligibility, 36 previously untrained candidates declined participation. 110 participants, distributed into four groups, completed the study: the previously untrained non-guided group (group A, n=30), the previously untrained guided group (group B, n=30), the previously trained non-guided group (group C, n=25) and the previously trained guided group (group D, n=25). Results of the Cardiff test and global evaluation of CPR performance revealed a significant improvement in group B as compared with group A, approaching the level of the group C. Previously trained guided bystanders had the best CPR scores, notably because of an improvement in the quality of airway management.

CONCLUSION

When used by dispatchers, this new French-language algorithm offers the opportunity to help previously untrained bystanders initiate CPR. The same protocol may serve to guide volunteers with prior basic life support training to reach their best CPR performance.

The effect of a cellular-phone video demonstration to improve the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation as compared with audio coaching

OBJECTIVE

Bystander cardiopulmonary resuscitation (CPR) has shown to significantly improve the survival of cardiac-arrest victims. Dispatcher assistance increases the number of bystanders who perform CPR, but the quality of CPR remains unsatisfactory. This study was conducted to assess the effect of video coaching on the performance of CPR by untrained volunteers when compared with traditional audio instruction in simulated cardiac arrests.

METHODS

Adult volunteers were randomised to receive audio-assisted instructions (audio group=39), or video-demonstrated instructions (video group=39) via cellular phones on how to perform chest compressions on mannequins. Then, the volunteers' performances were video-recorded. The quality of CPR was evaluated by reviewing the videos and mannequin reports.

RESULTS

For the video group, the chest compression rate was more optimal (99.5min(-1) vs. 77.4min(-1), P<0.01) and the time from the initial phone call to the first compressions was shorter (184s vs. 211s, P<0.01). The depth of compressions was deeper in the audio group (31.3mm vs. 27.5mm, P=0.21), but neither group performed the recommended depth of compression. The hand positions for compression were more appropriate in the video group (71.8% vs. 43.6%, P=0.01). As many as 71.8% of the video group had no 'hands-off' events when performing compression (vs. 46.2% for the audio group, P=0.02).

CONCLUSIONS

Instructions from the dispatcher, along with a video demonstration of CPR, improved the time to initiate compression, the compression rate and the correct hand positioning. It also reduced the 'hands-off' events during CPR. However, emphasised instructions by video may be needed to increase the depth of compressions.

A randomized trial of the capability of elderly lay persons to perform chest compression only CPR versus standard 30:2 CPR

AIM OF THE STUDY

Early cardiopulmonary resuscitation (CPR) improves survival after cardiac arrest, but there is a discrepancy between the age group normally attending CPR-classes and the age group most likely to witness a cardiac arrest. We wanted to study if elderly lay persons could perform 10min of CPR on a realistic manikin with continuous chest compressions (CCC) and conventional CPR (30:2).

METHODS

Volunteers were tested 5-7 months after CPR-classes. They were randomized to CCC or 30:2, and to receive feedback (FB) or not. Quality of CPR, age adjusted maximum heart rate (HRmax), and subjective exhaustion ratings were measured and evaluated in a blinded fashion. Temporal development and group differences were evaluated with ANOVA procedures.

RESULTS

All 64 volunteers were able to perform CPR for 10min and rated their efforts as mild to moderate in concordance with a mean HRmax of 78%. Quality of CPR was similar in all groups, except for chest compression rate that was slightly higher and had less variability in the FB group. Overall chest compression depth was 41+/-4.5mm. Analysis of temporal development of chest compression depth revealed a small initial decline before leveling off. As expected, CCC group had less pauses and higher total number of chests compressions.

CONCLUSION

Lay people in the age group 50-76 were able to perform CPR with acceptable quality for 10min and we found only very slight temporal quality deterioration. This makes training programs for the elderly meaningful to improve survival after cardiac arrest.

Evaluation of telephone-cardiopulmonary resuscitation advice for paediatric cardiac arrest

INTRODUCTION

Telephone-cardiopulmonary resuscitation (CPR) advice aims to increase the quality and quantity of bystander CPR, one of the few interventions shown to improve outcome in cardiac arrest. We evaluated a current paediatric telephone protocol (AMPDS v11.1) to assess the effectiveness of verbal CPR instructions in paediatric cardiac arrest.

METHODS

Consecutive emergency calls classified by the AMPDS as cardiac arrests in children <8 years old, over an 11 month period, were compared with their corresponding patient report forms (PRFs) to confirm the diagnosis. Audio recordings and PRFs were then evaluated to assess whether bystander CPR was given, and when it was, the time taken to perform CPR interventions, before paramedic arrival.

RESULTS

Of the 42 calls reviewed, 19 (45.2%) were confirmed as cardiac arrest. CPR was already underway in two cases (10.5%). Of the remaining callers, 11 (64.7%) agreed to attempt T-CPR, resulting in an overall bystander-CPR rate of 68.4%. The median time to open the airway was 126s (62-236s, n=11), deliver the first ventilation was 180s (135-360s, n=11), and perform the first chest compression was 280s (164-420s, n=9).

CONCLUSION

Although current telephone-CPR instructions improve the numbers of children in whom bystander CPR is attempted, effectiveness is likely to be limited by the significant delays in actually delivering basic life support.

Interactive video instruction improves the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation in simulated cardiac arrests

OBJECTIVE

Bystander cardiopulmonary resuscitation (CPR) significantly improves survival of cardiac arrest victims. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR remains unsatisfactory. This study was conducted to assess the effect of adding interactive video communication to dispatch instruction on the quality of bystander chest compressions in simulated cardiac arrests.

DESIGN

A randomized controlled study with a scenario developed to simulate cardiac arrest in a public place.

SETTING

The victim was simulated by a mannequin and the cell phone for dispatch assistance was a video cell phone with both voice and video modes. Chest compression-only CPR instruction was used in the dispatch protocol.

SUBJECTS

Ninety-six adults without CPR training within 5 years were recruited.

INTERVENTIONS

The subjects were randomized to receive dispatch assistance on chest compression with either voice instruction alone (voice group, n = 53) or interactive voice and video demonstration and feedback (video group, n = 43) via a video cell phone.

MEASUREMENTS AND MAIN RESULTS

Performance of chest compression-only CPR throughout the scenario was videotaped. The quality of CPR was evaluated by reviewing the videos and mannequin reports. Chest compressions among the video group were faster (median rate 95.5 vs. 63.0 min-1, p < 0.01), deeper (median depth 36.0 vs. 25.0 mm, p < 0.01), and of more appropriate depth (20.0% vs. 0%, p < 0.01). The video group had more "hands-off" time (5.0 vs. 0 second, p < 0.01), longer time to first chest compression (145.0 vs. 116.0 seconds, p < 0.01) and total instruction time (150.0 vs. 121.0 seconds, p < 0.01).

CONCLUSION

The addition of interactive video communication to dispatcher-assisted chest compression-only CPR initially delayed the commencement of chest compressions, but subsequently improved the depth and rate of compressions. The benefit was achieved mainly through real-time feedback.

Handling of drug-related emergencies: an evaluation of emergency medical dispatch

AIMS

Documenting the quality of emergency dispatch centres handling of emergency calls regarding intoxicated unconscious patients.

METHODS

Interview with eight emergency dispatch centre directors and a nationwide survey among 313 dispatchers in Norway were performed. In addition, a customized scoring system was used to evaluate dispatcher log recordings of real cases. The recordings were compared with information from corresponding ambulance records.

RESULTS

Ninety-nine percent of the dispatchers stated that they used the Norwegian protocol for medical emergencies and 89% of them found it useful. The interviews, the survey, and the recordings, however, documented frequent deviation from the protocol. This instructs ambulance dispatch for any unconscious patient, but 21% stated that they would not dispatch any resource for an unconscious patient without further survey in alcohol-related cases. This was significantly more often (P<0.05) than for the narcotic, combination and prescription - drug-related cases with 4, 10 and 7%, respectively. The recordings revealed deviation from the protocol with dispatchers only determining the patients' level of consciousness and respiratory status in 64 and 70% of the cases, respectively. For 16% of the cases, the dispatcher did not ask the caller about consciousness at all, even though these patients later were found with reduced consciousness.

CONCLUSION

On the basis of the interviews and the survey, cases were handled according to guidelines. The log recordings, however, disclosed deviation from the protocol. Alcohol intoxication was associated with higher rate of deviation from the protocol compared with other intoxications.

Can video mobile phones improve CPR quality when used for dispatcher assistance during simulated cardiac arrest?

BACKGROUND

Because mobile telephones may support video calls, emergency medical dispatchers may now connect visually with bystanders during pre-hospital cardio-pulmonary resuscitation (CPR). We studied the quality of simulated dispatcher-assisted CPR when guidance was delivered to rescuers by video calls or audio calls from mobile phones.

METHODS

One hundred and eighty high school students were randomly assigned in groups of three to communicate via video calls or audio calls with experienced nurse dispatchers at a Hospital Emergency Medical Dispatch Center. CPR was performed on a recording resuscitation manikin during simulated cardiac arrest. Quality of CPR and time factors were compared depending on the type of communication used.

RESULTS

The median CPR time without chest compression ('hands-off time') was shorter in the video-call group vs. the audio-call group (303 vs. 331 s; P=0.048), but the median time to first compression was not shorter (104 vs. 102 s; P=0.29). The median time to first ventilation was insignificantly shorter in the video-call group (176 vs. 205 s; P=0.16). This group also had a slightly higher proportion of ventiliations without error (0.11 vs. 0.06; P=0.30).

CONCLUSION

Video communication is unlikely to improve telephone CPR (t-CPR) significantly without proper training of dispatchers and when using dispatch protocols written for audio-only calls. Improved dispatch procedures and training for handling video calls require further investigation.

Video quality of 3G videophones for telephone cardiopulmonary resuscitation

We simulated a cardiopulmonary resuscitation (CPR) scene with a manikin and used two 3G videophones on the caller's side to transmit video to a laptop PC. Five observers (two doctors with experience in emergency medicine and three paramedics) evaluated the video. They judged whether the manikin was breathing and whether they would give advice for CPR; they also graded the confidence of their decision-making. Breathing was only visible from certain orientations of the videophones, at distances below 150 cm with good illumination and a still background. Since the phones produced a degradation in colours and shadows, detection of breathing mainly depended on moving contours. Low camera positioning produced better results than having the camera high up. Darkness, shaking of the camera and a moving background made detection of breathing almost impossible. The video from the two 3G videophones that were tested was of sufficient quality for telephone CPR provided that camera orientation, distance, illumination and background were carefully chosen. Thus it seems possible to use 3G videophones for emergency calls involving CPR. However, further studies on the required video quality in different scenarios are necessary.