A centralized system for providing dispatcher assisted CPR instructions to 9-1-1 callers at multiple municipal public safety answering points

BACKGROUND

Dispatcher CPR instruction increases the odds of survival. However, many communities do not provide this lifesaving intervention, often citing the barriers of limited personnel, funding, and liability.

OBJECTIVE

Describe the implementation of a novel centralized dispatcher CPR instruction program that serves seven public safety answering points (PSAPs).

METHODS

Seven municipal PSAPs that did not previously provide dispatcher instructions implemented our program. Using a 30-min self-directed video, 84 PSAP dispatchers were trained to utilize a two-question protocol to identify and transfer suspected out-of-hospital cardiac arrest (OHCA) cases to a central communication center. At this central communication center, a trained communicator delivered CPR instructions to the caller. The 26 central communicators were trained with a 2-h in-person didactic session followed by a 2-h practice session. We collected and analyzed data from recordings of communicator-to-caller interactions.

RESULTS

169 calls were transferred to the central communication center. Of those, 106 needed CPR instructions and 56 of those callers performed chest compressions (53%). The county-wide EMS documented bystander CPR rate was 20% the prior year. The 63 remaining transferred calls were non-OHCA calls. Of the calls where CPR was needed and performed, 11 victims survived to hospital discharge (20%); the countywide survival rate was 12%.

CONCLUSIONS

Using a central communication center for instructions allowed us to train and maintain a smaller group of communicators, leading to less cost and more experience for those communicators, while limiting the burden on PSAP dispatchers.

A Novel Use of a Metronome in Dispatcher-assisted Cardiopulmonary Resuscitation

Abstract Early, high-quality cardiopulmonary resuscitation (CPR) is the key to increasing the likelihood of successful resuscitation in cardiac arrest. The use of dispatch-assisted (DA) CPR can increase the likelihood of bystander CPR. We describe a case in which a metronome was introduced to guide DA-CPR. The wife of a 52-year-old male activated 9-1-1 after her husband suffered a cardiac arrest. During her 9-1-1 call she received CPR instructions and heard a metronome over the phone while following the instructions. Return of spontaneous circulation of the patient occurred during paramedic on scene care. The patient was transported to hospital and discharged 6 days later with no neurological deficit. This case supports the use of a metronome by emergency medical dispatchers during the provision of DA-CPR to improve bystander CPR.

A consensus-based gold standard for the evaluation of mass casualty triage systems

INTRODUCTION

Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems.

OBJECTIVE

To develop a consensus-based, functional gold standard definition for each mass casualty triage category.

METHODS

National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved.

RESULTS

Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved.

CONCLUSION

A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

The effect of Combitube use on paramedic experience in endotracheal intubation

OBJECTIVE

To determine the change in number of endotracheal intubations per paramedic after the implementation of Combitube use and to explore consequences.

METHODS

Before-and-after study; urban/suburban EMS system; population 1 million. Number of patients 16 years and older, type of airway used, attempts, and successes were abstracted for time periods before and after the use of Combitubes. The number of endotracheal intubations/paramedic for each period was calculated.

RESULTS

Three-year pre-Combitube: patients 50983; 6.6% arrests; 3142 received an endotracheal intubation attempt with 93.5% success. The average annual number of paramedics was 153 with 6.9 +/- 6.4 intubations per paramedic per year. Three-year post-Combitube: patients 55959; 6.0% arrests; 2913 received an advanced airway attempt: 860 Combitubes, success 89.4%; 2144 endotracheal intubations, success 91.6% (95% confidence interval success rate difference, 0.5-3.3; P = .007). The average annual number of paramedics was 177 with 3.7 +/- 3.3 intubations per paramedic per year.

CONCLUSION

After implementation of the Combitube, the number of endotracheal intubation attempts/paramedic and success rates decreased.

Lessons learned from an emergency medical services fire safety intervention

OBJECTIVE

The authors conducted a pilot study, finding that many households that experienced fires had received prior emergency medical services (EMS) visits, but few had operational smoke alarms. The study hypothesis is that dwellings that received smoke alarms and/or batteries during an EMS call were more likely to have an operational alarm, less property dollar loss, and decreased morbidity and mortality at the time of a subsequent fire.

METHODS

Smoke detectors and batteries were provided to an urban fire department for placement in unprotected homes at the time of an EMS call from March 1, 1999, through January 31, 2001. After addressing the reason for the 911 EMS call, verification or installation of an operational smoke alarm was performed. The authors examined records for dwellings that had a subsequent fire for outcomes of smoke alarm status, estimated property dollar loss, and number of injuries and fatalities.

RESULTS

This program placed 1,335 smoke detectors. Of these, 99 dwellings were found to have a fire or smoke condition with 20 exclusions. Our final number was 79; 28 (35%) still had an operating smoke alarm. In homes with operational alarms, the mean dollar loss was 2,870 dollars (U.S. 2001) (95% confidence interval [CI], 143-5,596). In homes without operational alarms, mean loss was 10,468 dollars (U.S. 2001) (95% CI, 5,875-15,061). No injuries or fatalities occurred in either group.

CONCLUSION

This program was successful in placing 1,335 smoke alarms in at-risk dwellings and reaffirmed that an operational smoke alarm significantly decreases property dollar loss. However, if the goal is to have all homes protected by smoke alarms, this program has long-term effectiveness limitations.

Ambulance sphygmomanometers are frequently inaccurate

OBJECTIVE

To determine the accuracy and reliability of sphygmomanometers used in a metropolitan emergency medical services (EMS) system.

METHODS

As a cross-sectional, convenience sample, 150 sphygmomanometers used by EMS personnel in Milwaukee County, Wisconsin, were evaluated. Each sphygmomanometer was checked for accuracy by connecting the manometer to a new, standard mercury manometer using a "Y" connector. Pressure was checked at readings of 60, 90, 120, and 200 mm Hg. The integrity of the device (leaking) was checked by inflating the cuff around a can to 300 mm Hg and measuring the pressure lost in 1 minute. Devices were determined to be inaccurate if the average of the absolute differences at each pressure deviated by more than 3 mm Hg. The device was determined to be unreliable (leaked) if it lost pressure greater than 15 mm Hg in 1 minute.

RESULTS

Twenty-eight percent (41/149) of the devices were inaccurate at 90 mm Hg and 25% (37/149) were inaccurate overall. The overall and 90 mm Hg average deviations were +/- 6.6 and +/- 6.0 mm Hg, respectively. Sixty-three percent (94/150) of the devices were unreliable (leaked). When considering both accuracy and reliability at 90 mm Hg, a total of 73% (109/150) of the devices failed one or both of the criteria.

CONCLUSION

This study suggests that an accurate blood pressure measurement may not be reliably obtained with 73% of the sphygmomanometers currently used in the county's EMS system.