Possibilities of implementing dispatcher-assisted cardiopulmonary resuscitation in the community. An evaluation of 99 consecutive out-of-hospital cardiac arrests

Strategies to improve communication in telementoring in acute care coordination: a scoping review

Background

Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring.

Methods

Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme.

Results

We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment.

Conclusion

The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

Protocol: simulation training to improve 9-1-1 dispatcher identification of cardiac arrest

Background

9-1-1 dispatchers are often the first contact for bystanders witnessing an out-of-hospital cardiac arrest. In the time before Emergency Medical Services arrives, dispatcher identification of the need for, and provision of Telephone-CPR (T-CPR) can improve survival. Our study aims to evaluate the use of phone-based standardized patient simulation training to improve identification of the need for T-CPR and shorten time to start of T-CPR instructions.

Methods/Design

The STAT-911 study is a randomized controlled trial. We will recruit 160 dispatchers from 9-1-1 call-centers in the Pacific Northwest; they are randomized to an intervention or control group. Intervention participants complete four telephone simulation training sessions over 6–8 months. Training sessions consist of three mock 9-1-1 calls, with a standardized patient playing a caller witnessing a medical emergency. After the mock calls, an instructor who has been listening in and scoring the dispatcher’s call management, connects to the dispatcher and provides feedback on select call processing skills. After the last training session, all participants complete the simulation test: a call session that includes two mock 9-1-1 calls of medium complexity. During the study, audio from all actual cardiac arrest calls handled by the dispatchers will be collected. All dispatchers complete a baseline survey, and after the intervention, a follow-up survey to measure confidence. Primary outcomes are proportion of calls where dispatchers identify the need for T-CPR, and time to start of T-CPR, assessed by comparing performance on two calls in the simulation test. Secondary outcomes are proportion of actual cardiac arrest calls in which dispatchers identify the need for T-CPR and time to start of T-CPR; performance on call-taking skills during the simulation test; self-reported confidence in the baseline and follow-up surveys; and calculated costs of the intervention training sessions and projected costs for field implementation of training sessions.

Discussion

The STAT-911 study will evaluate if over-the-phone simulation training with standardized patients can improve 9-1-1 dispatchers’ ability identify the need for, and promptly begin T-CPR. Furthermore, it will advance knowledge on the effectiveness of simulation training for health services phone-operators interacting with clients, patients, or bystanders in diagnosis, triage, and treatment decisions.

Trial registration

ClinicalTrials.gov Registration Number: NCT01972087. Registered 23 October 2013.

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.

Barriers and opportunities in assessing calls to emergency medical communication centre--a qualitative study

INTRODUCTION

Previous studies have described the difficulties and the complexity of assessing an emergency call, and assessment protocols intended to support the emergency medical dispatcher's (EMD) assessment have been developed and evaluated in recent years. At present, the EMD identifies about 50-70 % of patients suffering from cardiac arrest, acute myocardial infarction or stroke. The previous research has primarily been focused on specific conditions, and it is still unclear whether there are any overall factors that may influence the assessment of the call to the emergency medical communication centre (EMCC).

AIM

The aim of the study was to identify overall factors influencing the registered nurses' (RNs) assessment of calls to the EMCC.

METHOD

A qualitative study design was used; a purposeful selection of calls to the EMCC was analysed by content analysis.

RESULTS

One hundred calls to the EMCC were analysed. Barriers and opportunities related to the RN or the caller were identified as the main factors influencing the RN's assessment of calls to the EMCC. The opportunities appeared in the callers' symptom description and the communication strategies used by the RN. The barriers appeared in callers' descriptions of unclear symptoms, paradoxes and the RN's lack of communication strategies during the call.

CONCLUSION

Barriers in assessing the call to the EMCC were associated with contradictory information, the absence of a primary problem, or the structure of the call. Opportunities were associated with a clear symptom description that was also repeated, and the RN's use of different communication strategies such as closed loop communication.

An evaluation of 9-1-1 calls to assess the effectiveness of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions: design and methodology

Background

Cardiac arrest is the leading cause of mortality in Canada, and the overall survival rate for out-of-hospital cardiac arrest rarely exceeds 5%. Bystander cardiopulmonary resuscitation (CPR) has been shown to increase survival for cardiac arrest victims. However, bystander CPR rates remain low in Canada, rarely exceeding 15%, despite various attempts to improve them. Dispatch-assisted CPR instructions have the potential to improve rates of bystander CPR and many Canadian urban communities now offer instructions to callers reporting a victim in cardiac arrest. Dispatch-assisted CPR instructions are recommended by the International Guidelines on Emergency Cardiovascular Care, but their ability to improve cardiac arrest survival remains unclear.

Methods/Design

The overall goal of this study is to better understand the factors leading to successful dispatch-assisted CPR instructions and to ultimately save the lives of more cardiac arrest patients. The study will utilize a before-after, prospective cohort design to specifically: 1) Determine the ability of 9-1-1 dispatchers to correctly diagnose cardiac arrest; 2) Quantify the frequency and impact of perceived agonal breathing on cardiac arrest diagnosis; 3) Measure the frequency with which dispatch-assisted CPR instructions can be successfully completed; and 4) Measure the impact of dispatch-assisted CPR instructions on bystander CPR and survival rates.

The study will be conducted in 19 urban communities in Ontario, Canada. All 9-1-1 calls occurring in the study communities reporting out-of-hospital cardiac arrest in victims 16 years of age or older for which resuscitation was attempted will be eligible. Information will be obtained from 9-1-1 call recordings, paramedic patient care reports, base hospital records, fire medical records and hospital medical records. Victim, caller and system characteristics will be measured in the study communities before the introduction of dispatch-assisted CPR instructions (before group), during the introduction (run-in phase), and following the introduction (after group).

Discussion

The study will obtain information essential to the development of clinical trials that will test a variety of educational approaches and delivery methods for telephone cardiopulmonary resuscitation instructions. This will be the first study in the world to clearly quantify the impact of dispatch-assisted CPR instructions on survival to hospital discharge for out-of-hospital cardiac arrest victims.

Trial Registration

ClinicalTrials.gov NCT00664443

To see or not to see--better dispatcher-assisted CPR with video-calls? A qualitative study based on simulated trials

BACKGROUND

Video communication through mobile telephone is now available in many parts of the world. We ask how mobile phone video-calls compares with traditional phone calls for dispatcher-assisted cardiopulmonary resuscitation (T-CPR).

METHODS

Primary data was collected through individual interviews with six dispatchers after their participation in simulated cardiac arrest. They had 10 scenarios each, during which they guided rescuers on resuscitation. During half of the scenarios they used video-calls, and traditional phone calls for the rest. Concepts from modern systems theory were used to analyse the material.

RESULTS

Video-calls influenced the information basis and understanding of the dispatchers. The dispatchers experienced that (1) video-calls are useful for obtaining information and provides adequate functionality to support CPR assistance; (2) their CPR assistance becomes easier; (3) the CPR might be of better quality; but (4) there is a risk of "noise".

DISCUSSION

We emphasize visual observation as a way of constructing professional understanding when using video-calls, which may provide a new basis for dispatcher assistance. Video-calls may improve rescuer compliance. The role and content of telephone-directed protocols used by dispatchers may need adjustments when video-calls are used for medical emergencies.

CONCLUSION

Video communication can improve the dispatchers' understanding of the rescuer's situation, and the assistance they provide.

Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions

OBJECTIVES

To determine the frequency of agonal breathing during cardiac arrest (CA), its impact on the ability of 9-1-1 dispatchers to identify CA, and the impact of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions on bystander CPR rates.

METHODS

A before-after observational study enrolling out-of-hospital adult CA patients where resuscitation was attempted in a single city with basic life support with defibrillation/advanced life support tiered emergency medical services. Victim, caller, and system characteristics were measured during two successive nine-month periods before (control group) and after (intervention group) the introduction of dispatch-assisted CPR instructions.

RESULTS

There were 529 CAs between July 1, 2003, and December 31, 2004. Victim characteristics were similar in the control (n = 295) and intervention (n = 234) period; mean age was 68.3 years; 66.7% were male; 50.1% of CAs were witnessed; call-to-vehicle stop was 6 minutes, 37 seconds; ventricular fibrillation/ventricular tachycardia occurred in 29.9%; and the survival rate was 4.0%. Dispatchers identified 56.3% (95% confidence interval [CI] = 48.9% to 63.0%) of CA cases; agonal breathing was present in 37.0% (95% CI = 30.1% to 43.9%) of all CA cases and accounted for 50.0% (95% CI = 39.1% to 60.9%) of missed diagnoses. Callers provided ventilations in 17.2% and chest compressions in 8.3% of cases as a result of the intervention. Long time intervals were observed between call to diagnosis (2 minutes, 38 seconds) and during ventilation instructions (2 minutes, 5 seconds). Bystander CPR rates increased from 16.7% in the control phase to 26.4% in the intervention phase (absolute rate, 9.7%; 95% CI = 8.5% to 11.3%; p = 0.006).

CONCLUSIONS

This trial demonstrates an increase in bystander CPR rate after the introduction of dispatch-assisted CPR. Agonal breathing occurred frequently and had a negative impact on the recognition of CA. There were long time intervals between call initiation and diagnosis of CA and during mouth-to-mouth ventilation instructions.

Initial emergency medical dispatching and prehospital needs assessment: a prospective study of the Swedish ambulance service

OBJECTIVES

To evaluate the setting of priorities and patients' need for the ambulance service.

METHODS

A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case.

RESULTS

The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff.

CONCLUSION

Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

Effect of protocol compliance to cardiac arrest identification by emergency medical dispatchers

OBJECTIVES

The objective of the study was to assess the effect of protocol compliance to the accuracy of cardiac arrest (CA) identification by the dispatchers.

METHODS

The study was conducted prospectively over a 1-year period in 1996. The calls categorized as non-traumatic CAs by the dispatcher and calls where the patient was in non-traumatic CA when ambulance crew arrived were included in the study. The data was collected from emergency call tape recordings and ambulance run sheets. The compliance to the protocol was defined as gathering information to two questions: (1) Is the patient awake or can she/he be awakened? and (2) Is she/he breathing normally?

RESULTS

The number of calls included in the study was 776 and the dispatchers identified 83% of the CAs. The protocol was adhered in 52.4% of calls, more often in witnessed than unwitnessed cases (72.3% versus 45.0%, P<0.001). In correctly identified CAs, the protocol compliance was 49.4%. The compliance was higher in cases of unidentified CAs (60.3%, P=0.0326) and in cases of wrongly identified as CAs (false positives, 61.9%, P=0.0276).

CONCLUSIONS

A high identification rate of CAs seems to be achievable despite poor protocol compliance by dispatchers.

To blow or not to blow: a randomised controlled trial of compression-only and standard telephone CPR instructions in simulated cardiac arrest

This randomised controlled trial used a manikin model of cardiac arrest to compare skill performance in untrained lay persons randomised to receive either compression-only telephone CPR (Compression-only tel., n=29) or standard telephone CPR instructions (Standard tel., n=30). Performance was evaluated during standardised 10 min cardiac arrest simulations using a video recording and data from a laptop computer connected to the training manikin. A number of subjects in both groups did not open the airway. More than 75% in the Standard tel. group failed to deliver two effective initial rescue breaths, and only 17% provided an adequate inflation volume for subsequent breaths, delivering a median of only five inflations during the entire scenario. Most subjects in both groups gave chest compressions that were too shallow and at an inappropriately rapid rate. Hand position was also poor, but was worse in the group given simplified instructions. There was a significant delay to first compression in both groups, although this interval was shortened by over a minute when ventilations were eliminated from the telephone instruction algorithm (245 vs. 184 s, P<0.001). Over two-and-a-half times as many chest compressions were delivered during an average ambulance response time with compression-only telephone directions compared with standard CPR (461 vs. 186, P<0.001). These variables may be critical in predicting survival from out-of-hospital cardiac arrest. Further research is necessary to establish if modifications to scripted telephone instructions can remedy the identified performance deficiencies. Eliminating instructions for rescue breaths from scripted telephone directions will have little impact on the ventilation of most patients. Research is required to determine if the consequent reduction in the delay to starting chest compressions and the significant increase in the number of compressions delivered can increase survival from out-of-hospital cardiac arrest.

Perceived Self-Efficacy in Performing and Willingness to Learn Cardiopulmonary Resuscitation in an Elderly Population in a Suburban Community

• Background Older persons are the group most likely to respond to cardiac arrests in private residences.

• Objective To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation.

• Methods A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention.

• Results The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P &lt; .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P &lt; .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent’s spouse.

• Conclusion Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training.

Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases

AIM

One of the objectives of this study was to assess the emergency medical dispatchers (EMDs) ability for the identification and prioritisation of cardiac arrest (CA) cases, and offering and achievements of dispatcher-assisted bystander cardiopulmonary resuscitation (CPR). The other objective was to give an account of the frequency of agonal respiration in cardiac arrest calls and the caller's descriptions of breathing.

METHODS

Prospective study evaluating 100 tape recordings of the EMD calls of emergency medical service (EMS)-provided advanced life support- (ALS) cases, of out-of-hospital cardiac arrest.

RESULTS

The quality of EMD-performed interviews was highly commended in 63% of cases, but insufficient or unapproved in the remaining 37%. The caller's state of mind was not a major problem for co-operation. Among the 100 cases, 24 were suspected to be unconscious and in respiratory arrest. A further 38 cases were presented as unconscious with abnormal breathing. In only 14 cases dispatcher-assisted bystander CPR was offered by the EMD, and in 11 of these it was attempted, and completed in eight. Only four of the cases were unconscious patients with abnormal breathing. The incidence of suspected agonal breathing was estimated to be approximately 30% and the descriptions were; difficulty, poorly, gasping, wheezing, impaired, occasional breathing.

CONCLUSIONS

Among suspected cardiac arrest cases, EMDs offer CPR instruction to only a small fraction of callers. A major obstacle was the presentation of agonal breathing. Patients with a combination of unconsciousness and agonal breathing should be offered dispatcher-assisted CPR instruction. This might improve survival in out-of hospital cardiac arrest.

Dispatcher-assisted telephone CPR: a qualitative study exploring how dispatchers perceive their experiences

OBJECTIVES

To investigate how emergency medical dispatchers (EMDs) perceive their experience of identifying suspected cardiac arrests (CA), and offer and provide instructions in cardiopulmonary resuscitation via telephone (t-CPR).

DESIGN

A qualitative method using the phenomenographic design where 10 EMDs were approached for semi-structured interviews.

MAIN OUTCOME MEASURES

Perception in identifying CA, perception in offering t-CPR and perception in providing t-CPR.

RESULTS

In this analysis, 12 categories and 31 subcategories emerged. The categories for perception in identifying CA were; to trust the witness's account, to be open-minded and to be organised. The categories for perception in offering t-CPR were: to feel prepared to connect with the witness on a mental level by being organised, flexible and supportive, to obtain a basis for assessments and to be observant for diverse obstacles in a situation. Finally, the categories for perception in providing t-CPR were: to feel engaged, to be supportive of the witness, to feel secure by recognising response-feedback from the witness, to observe external conditions with regard to the locality and technical complications, to be composed and adjust to the needs of the situation, to feel competent or to feel despair.

CONCLUSIONS

By listening in an open-minded way, a vast amount of information can be collected. Using criteria-based dispatch (CBD) and their own resources, the possibilities and difficulties of the situation are analysed. The EMDs believe that they are being an empathic support, relieving the witness of the burden of responsibility, and connecting with them mentally to enable them to act at the scene. There are EMDs who feel competent and experienced in managing these cases, and other EMDs who feel insecure and despair. The choice between providing t-CPR and answering incoming calls is prioritised differently among EMDs. There is also a broad subjective assessment among EMDs of offering t-CPR, especially to persons over 70 years old whom they consider incapable of performing CPR. The competence of the EMDs in t-CPR is dependent on re-training and a feedback on patient outcome. Witnesses who are negative towards acting constitute a common problem. There are witnesses with physical impediments or psychologically not susceptible to suggestions. The EMD is also dependent on the knowledge and trustworthiness of the witness. Convincing answers from witnesses prompt a more secure feeling in the EMDs, just as lack of knowledge in the witness has a negative effect on the efforts.

Do health care professionals report sudden cardiac arrest better than laymen?

OBJECTIVE

To compare the emergency calls made by health care providers and by laymen reporting a non-traumatic cardiac arrest, and to evaluate the handling of these calls by dispatchers.

METHODS

The study was conducted prospectively over a 1-year period in 1996. The callers (N=328) where divided in to three groups based on profession: I, doctors and nurses (N=33); II, other health care providers (N=19); and III, laymen (N=276). Main outcome measures where the information given by the caller, use of the dispatching protocol, recognition of the cardiac arrest, and survival to hospital.

RESULTS

Doctors and nurses told the dispatcher spontaneously what had happened in 67% of the calls when total strangers to the patient told it in 72%. Group I gave no information about the vital signs in 24% of the calls, group II in 0% and group III in 6%. Of the 52 phone calls made by groups I and II, in six cases the patient was not in cardiac arrest, in four the patient had already irreversible signs of death and in four only transportation to another hospital was requested for a patient in cardiac arrest. Of the professionals calling, 49 (94%) were on duty at the time of the call. The cardiac arrest was recognized by the dispatcher in group I in 70%, in group II in 74% and in group III in 73%. There where no statistical differences between the groups.

CONCLUSIONS

Our data do suggest that health care professionals, excluding those in emergency medicine, are not better than laymen in evaluating an emergency situation correctly, and when the caller is a doctor or a nurse the dispatcher seems to trust the evaluation of the situation to be correct and rarely asks any clarifying questions about vital signs of the patient.