Description of call handling in emergency medical dispatch centres in Scandinavia: recognition of out-of-hospital cardiac arrests and dispatcher-assisted CPR

Patient cohorts of interest in resuscitation science - Aligning cardiac arrest registry outputs with stakeholder needs

INTRODUCTION

Cardiac arrest registries can benchmark, enhance quality of care and provide data for research. Key stakeholders from Emergency Medical Communication Centre (EMCC), Emergency Medical Services (EMS), In-Hospital Care Providers (IHCP) and Recovery and Rehabilitation Providers (RRP) have different perspectives, and registry results and patient cohorts should be tailored to facilitate benchmarking, quality improvement projects and research in all sections of the chain of survival. In this paper, we describe different cohorts of interest, exemplified by data from the Norwegian Cardiac Arrest Registry (NorCAR).

METHOD

Data from NorCAR for patients registered in 2022 is presented as descriptive statistics.

RESULTS

The patient cohort with treatment initiated by EMCC comprised 3591 patients (67/100,000 inhabitants). EMS attended 4150 patients with confirmed cardiac arrest (77/100,000 inhabitants) and started cardiopulmonary resuscitation (CPR) in 3083 patients (57/100,000 inhabitants). The patient cohort eligible for treatment by IHCP consists of 1114 patients admitted to hospital alive or with ongoing CPR, along with 1230 in-hospital cardiac arrest cases. The cohort eligible for rehabilitation and follow-up consists of 1227 patients who were alive 24 h after cardiac arrest, 705 out-of-hospital cardiac arrests and 522 in-hospital cardiac arrests.

CONCLUSION

It is essential to clearly define the cohort of interest when engaging with different stakeholders and to provide data that facilitates quality improvement projects in all areas of the chain of survival. We recommend defining several subgroups of cardiac arrest patients to accommodate benchmarking, quality improvement projects and research relevant for all stakeholders involved in resuscitation and care of cardiac arrest patients.

Language barriers in emergency ambulance calls for cardiac arrest: Cases of missing vital information

In medical emergencies, phoning the ambulance service constitutes a high-stakes interaction. Call-takers rely on callers to provide information about the patient so they can promptly recognise the medical problem and take swift action to remedy it. When a language barrier exists between the call-taker and caller, this can add a further challenge, given that third-party interpreters are rarely engaged, especially for time-critical conditions such as cardiac arrest. Research in cardiac arrest calls has found that language barrier calls experience longer delays to critical points such as recognition of cardiac arrest and commencement of resuscitation. This study aimed to understand, in the absence of interpreters, the interactional challenges that emerged in language barrier emergency calls, as parties worked to communicate the nature of the medical problem. Based on a critical conversation analysis approach, we conducted fine-grained analysis of interactions in audio recordings and transcripts of 33 language barrier calls from an Australian ambulance service in 2019. We found that call takers regularly failed to recognise that the patient had a cardiac arrest. Non-fluent-English callers often provided vital information about the patient, which could have led to cardiac arrest recognition by the call-taker, however such information was missed if it was delivered in an unsolicited or atypical way. Opportunities to recognise cardiac arrest were also missed when call-takers did not probe further after such information was provided or did not provide enough interactional space for callers to complete their turns. We found that the main reason for delays in recognising cardiac arrest was a lack of mutual understanding, which most of the time seemed to remain unbeknownst to participants. The study makes recommendations for emergency medical dispatch centres to cater for language barrier calls, with the goal of fostering a more inclusive prehospital care system and addressing health disparities for non-fluent-English speakers.

Outline and validation of a new dispatcher-assisted cardiopulmonary resuscitation educational bundle using the Delphi method

Aim

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is time-dependent. To date, evidence-based training programmes for dispatchers are lacking. This study aimed to reach expert consensus on an educational bundle content for dispatchers to provide DA-CPR using the Delphi method.

Method

An educational bundle was created by the Swedish Resuscitation Council consisting of three parts: e-learning on DA-CPR, basic life support training and audit of emergency out-of-hospital cardiac arrest calls. Thereafter, a two-round modified Delphi study was conducted between November 2022 and March 2023; 37 experts with broad clinical and/or scientific knowledge of DA-CPR were invited. In the first round, the experts participated in the e-learning module and answered a questionnaire with 13 closed and open questions, whereafter the e-learning part of the bundle was revised. In the second round, the revised e-learning part was evaluated using Likert scores (20 items). The predefined consensus level was set at 80%.

Results

Delphi rounds one and two were assessed by 20 and 18 of the invited experts, respectively. In round one, 18 experts (18 of 20, 90%) stated that they did not miss any content in the programme. In round two, the scale-level content validity index based on the average method (S-CVI/AVE, 0.99) and scale-level content validity index based on universal agreement (S-CVI/UA, 0.85) exceeded the threshold level of 80%.

Conclusion

Expert consensus on the educational bundle content was reached using the Delphi method. Further work is required to evaluate its effect in real-world out-of-hospital cardiac arrest calls.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Potential to enhance telephone cardiopulmonary resuscitation with improved instructions - findings from a simulation-based manikin study with lay rescuers

BACKGROUND

Telephone-Cardiopulmonary Resuscitation (T-CPR) significantly increases rate of bystander resuscitation and improves patient outcomes after out-of-hospital cardiac arrest (OHCA). Nevertheless, securing correct execution of instructions remains a difficulty. ERC Guidelines 2021 recommend standardised instructions with continuous evaluation. Yet, there are no explicit recommendations on a standardised wording of T-CPR in the German language. We investigated, whether a modified wording regarding check for breathing in a German T-CPR protocol improved performance of T-CPR.

METHODS

A simulation study with 48 OHCA scenarios was conducted. In a non-randomised trial study lay rescuers were instructed using the real-life-CPR protocol of the regional dispatch centre and as the intervention a modified T-CPR protocol, including specific check for breathing (head tilt-chin lift instructions). Resuscitation parameters were assessed with a manikin and video recordings.

RESULTS

Check for breathing was performed by 64.3% (n = 14) of the lay rescuers with original wording and by 92.6% (n = 27) in the group with modified wording (p = 0.035). In the original wording group the head tilt-chin manoeuvre was executed by 0.0% of the lay rescuers compared to 70.3% in the group with modified wording (p < 0.001). The average duration of check for breathing was 1 ± 1 s in the original wording group and 4 ± 2 s in the group with modified wording (p < 0.001). Other instructions (e.g. check for consciousness and removal of clothing) were well performed and did not differ significantly between groups. Quality of chest compression did not differ significantly between groups, with the exception of mean chest compression depth, which was slightly deeper in the modified wording group.

CONCLUSION

Correct check for breathing seems to be a problem for lay rescuers, which can be decreased by describing the assessment in more detail. Hence, T-CPR protocols should provide standardised explicit instructions on how to perform airway assessment. Each protocol should be evaluated for practicability.

Are first responders first? The rally to the suspected out-of-hospital cardiac arrest

BACKGROUND

Time is the crucial factor in the "chain of survival" treatment concept for out-of-hospital cardiac arrest (OHCA). We aimed to measure different response time intervals by comparing emergency medical system (EMS), fire fighters and smartphone aided volunteer responders.

METHODS

In two large Swedish regions, volunteer responders were timed from the alert until they arrived at the scene of the suspected OHCA. The first arriving volunteer responders who tried to fetch an automated external defibrillator (AED-responder) and who ran to perform bystander cardiopulmonary resuscitation (CPR-responder) were compared to both the first arriving EMS and fire fighters. Three-time intervals were measured, from call to dispatch, the unit response time (from dispatch to arrival) and the total response time.

RESULTS

During 22 months, 2631 suspected OHCAs were included. The median time from call to dispatch was in minutes 1.8 (95% CI = 1.7-1.8) for EMS, 2.9 (95% CI = 2.8-3.0) for fire-fighters and 3.0 (95% CI = 2.9-3.1) for volunteer responders. The median unit response time was 8.3 (95% CI = 8.1-8.5) for EMS, 6.8 (95% CI = 6.7-6.9) for fire fighters and 6.0 (95% CI = 5.7-6.2) for AED-responders and 4.6 (95% CI = 4.5-4.8) for CPR-responders. The total response time was 10.4 (95% CI = 10.1-10.6) for EMS, 10.2 (95% CI = 9.9-10.4) for fire fighters, 9.6 (95% CI = 9.1-9.8) for AED-responders and 8.2 (95% CI = 8.0-8.3) for CPR-responders.

CONCLUSION

First arriving volunteer responders had the shortest unit response time when compared to both fire fighters and EMS, however this advantage was reduced by delays introduced at the dispatch center. Earlier automatic dispatch should be considered in further studies.

A scoping review to determine the barriers and facilitators to initiation and performance of bystander cardiopulmonary resuscitation during emergency calls

Background

To maximise out-of-hospital cardiac arrest (OHCA) patients' survival, bystanders should perform continuous, good quality cardiopulmonary resuscitation (CPR) until ambulance arrival.

Objectives

To identify published literature describing barriers and facilitators between callers and call-takers, which affect initiation and performance (continuation and quality) of bystander CPR (B-CPR) throughout the OHCA emergency call.

Eligibility criteria

Studies were included if they reported on the population (emergency callers and call-takers), concept (psychological, physical and communication barriers and facilitators impacting the initiation and performance of B-CPR) and context (studies that analysed OHCA emergency calls).

Sources of evidence

Medline, CINAHL, Cochrane CENTRAL, Embase, Scopus and ProQuest were searched from inception to 9 March 2022.

Charting methods

Study characteristics were extracted and presented in a narrative format accompanied by summary tables.

Results

Thirty studies identified factors that impacted B-CPR initiation or performance during the emergency call. Twenty-eight studies described barriers to the provision of CPR instructions and CPR initiation, with prominent themes being caller reluctance (psychological), physical ability (physical), and callers hanging up the phone prior to CPR instructions (communication). There was little evidence examining barriers and facilitators to ongoing CPR performance (2 studies) or CPR quality (2 studies).

Conclusions

This scoping review using emergency calls as the source, described barriers to the provision of B-CPR instructions and B-CPR initiation. Further research is needed to explore facilitators and barriers to B-CPR continuation and quality throughout the emergency call, and to examine the effectiveness of call-taker strategies to motivate callers to perform B-CPR.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Aim

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

Methods

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

Results

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

Conclusions

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

Out-of-hospital cardiac arrest: Does rurality decrease chances of survival?

Background

Geographical setting is seldomly taken into account when investigating out-of-hospital cardiac arrest (OHCA). It is a common notion that living in rural areas means a lower chance of fast and effective helpwhen suffering a time-critical event. This retrospective cohort study investigates this hypothesis and compares across healthcare-divided administrative regions.

Methods

We included only witnessed OHCAs to minimize the risk that outcome was predetermined by time to caller arrival and/or recognition. Arrests were divided into public and residential. Residential arrests were categorized according to population density of the area in which they occurred. We investigated incidence, EMS response time and 30-day survival according to area type and subsidiarily by healthcare-divided administrative region.

Results

The majority (71%) of 8,579 OHCAs were residential, and 53.2% of all arrests occurred in the most densely populated cell group amongst residential arrests. This group had a median EMS response time of six minutes, whereas the most sparsely populated group had a median of 10 minutes. Public arrests also had a median response time of six minutes. 30-day survival was highest in public arrests (38.5%, [95% CI 36.9;40.1]), and varied only slightly with no statistical significance between OHCAs in densely and sparsely populated areas from 14.8% (95% CI 14.4;15.2) and 13.4% (95% CI 12.2;14.7).

Conclusion

Our study demonstrates that while EMS response times in Denmark are longer in the rural areas, there is no statistically significant decrease in survival compared to the most densely populated areas.