Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.
AbstrastObjective. The goal of this investigation was to describe the reasons emergency medical services (EMS) is activated when resuscitation is not desired or when patients show signs of irreversible death. Methods. All medical incident report forms (MIRFs) indicating a cardiac arrest for which resuscitation was withheld were obtained from five participating fire departments. For each eligible case (N = 196), one of the emergency medical technicians (EMTs) present at the scene was interviewed and the dispatch tape of the 9-1-1 call was reviewed. Patient and caller characteristics were abstracted from the MIRFs and dispatch tapes. The EMTs were asked about the reasons for the call, whether the family expected this death, and the caller's emotional state when EMS arrived at the scene. In addition, EMS providers were asked open-ended questions about the services they provided for the patient and patient's family. Using chi-square statistics and t-tests, we compared two groups: 1) patients for whom resuscitation was not desired as indicated by a do-not-resuscitate (DNR) order, terminal illness, or hospice (n = 66) and 2) patients for whom resuscitation was not started because of signs of irreversible death (n = 130). Results. Compared with callers for patients with signs of irreversible death, callers for patients for whom resuscitation was not desired were less likely to access EMS because they needed medical assistance (11% versus 30%) and more likely to call 9-1-1 because they thought it was "required by law" (30% versus 8%). Other common reasons in both groups for activating 9-1-1 were confusion regarding what to do and a request to confirm death. The most frequently reported service provided by EMTs for both groups was to "offer to contact a chaplain." Conclusion. In a third of patients for whom EMS did not initiate resuscitation, resuscitation was withheld primarily because it was not desired rather than because there was evidence of irreversible death. Efforts to improve education may prevent EMS activation in these cases. An alternative EMS response could also help ensure patient autonomy and decrease costs to the EMS system.
Objective. We investigated 9-1-1 telecommunicators' perceptions of communication difficulties with callers who have limited English proficiency (LEP) and the frequency and outcomes of specific communication behaviors. Methods. A survey was administered to 150 telecommunicators from four 9-1-1 call centers of a metropolitan area in the Pacific Northwest to assess their experience working with LEP callers. In addition, 172 9-1-1 recordings (86 of which were labeled by telecommunicators as having a "language barrier") were abstracted for telecommunicators' communication behaviors and care delivery outcomes. All recordings were for patients who were in presumed cardiac arrest (patient unconscious and not breathing). Additionally, computer-assisted dispatch (CAD) reports were abstracted to assess dispatch practices with regard to timing of basic life support (BLS) and advanced life support (ALS) dispatch. Results. One hundred twenty-three of the telecommunicators (82%%) filled out the survey. The majority (70%%) reported that they encounter LEP callers almost daily and most (78%%) of them reported that communication difficulties affect the medical care these callers receive. Additionally, the telecommunicators reported that calls with LEP callers are often (36%%) stressful. The number one strategy for communication with LEP callers reported by telecommunicators was the use of a telephone interpreter line known as the Language Line. However, the Language Line was utilized in only 13%% of LEP calls abstracted for this study. The analysis of 9-1-1 recordings suggests that the LEP callers received more repetition, rephrasing, and slowing of speech than the non-LEP callers. Although there was no difference in time from onset of call to dispatching BLS, there was a significant difference in simultaneous dispatching of BLS and ALS between the LEP calls (20%%) and non-LEP calls (38%%, p < 0.05). Conclusion. Our study shows that 9-1-1 telecommunicators believe language barriers with LEP callers negatively impact communication and care outcomes. More research needs to be conducted on "best practices" for phone-based emergency communication with LEP callers. Additionally, LEP communities need to better understand the 9-1-1 system and how to effectively communicate during emergencies.
INTRODUCTION: The role of chest compression fraction (CCF) in resuscitation of shockable out-of-hospital cardiac arrest (OHCA) is uncertain. We evaluated the relationship between CCF and clinical outcomes in a secondary analysis of the Resuscitation Outcomes Consortium (ROC) PRIMED trial. METHODS: We included OHCA patients from the ROC PRIMED trial who suffered cardiac arrest prior to EMS arrival, presented with a shockable rhythm, and had cardiopulmonary resuscitation (CPR) process data for at least one shock. We used multivariable logistic regression adjusting for Utstein variables, CPR metrics of compression rate and perishock pause, and ROC site to determine the relationship between CCF and survival to hospital discharge, return of spontaneous circulation (ROSC), and neurologically intact survival defined with Modified Rankin Score (MRS) ≤ 3. Due to potential confounding between CCF and cases that achieved early ROSC, we also performed an analysis restricted to patients without ROSC in the first 10 minutes of EMS resuscitation. RESULTS: Among the 2,558 eligible patients, median (IQR) age was 65 (54, 76) years, 76.9% were male, and mean (SD) CCF was 0.70 (0.15). Compared to the reference group (CCF < 0.60), the odds ratio (OR) for survival was 0.57 (95%CI: 0.42, 0.78) for CCF 0.60-0.79 and 0.32 (95%CI: 0.22, 0.48) for CCF ≥0.80. Results were similar for outcomes of ROSC and neurologically intact survival. Conversely, when restricted to the cohort who did not achieve ROSC during the first 10 minutes (n=1,660), the relationship between CCF and survival was no longer significant. Compared to the reference group (CCF < 0.60), the OR for survival was 0.85 (95 %CI: 0.58, 1.26) for CCF 0.60-0.79 and OR 0.87 (95%CI: 0.58, 1.36) for CCF ≥0.80. CONCLUSIONS: In this observational cohort study of OHCA patients presenting in a shockable rhythm, CCF when adjusted for Utstein predictors, CPR metrics and ROC site was paradoxically associated with lower odds of survival. The relationship between CCF and clinical outcomes was null in a sensitivity analysis restricted to patients without ROSC in the first 10 minutes. CCF is a complex measure and taken by itself may not be a consistent predictor of clinical outcome.
Improving survival from out-of-hospital cardiac arrest is an ongoing challenge for emergency medical services (EMS). Various strategies for shortening the time from collapse to defibrillation have been used, and one is to equip police officers with defibrillators. Objective. We evaluated the programmatic implementation of police defibrillation to determine if such a program could improve the process of care in a high-functioning and mature EMS system.We conducted a prospective observational study of implementation of a police defibrillation in two police departments in King County, Washington, from March 1, 2010 to March 31, 2012. The program was designed to dispatch police specifically to cases with a high suspicion of cardiac arrest, defined as a patient who was unconscious and not breathing normally. We included all nontraumatic out-of-hospital cardiac arrest events that occurred prior to EMS arrival and within the city limits of the two cities. We collected both EMS and police dispatch reports to document times of call receipt, dispatch, and arrival of both agencies. We obtained rhythm recordings when the automated external defibrillators (AEDs) were used by the police. Descriptive statistics were used to measure frequency of police dispatch and to compare times to treatment between patients with a police response and those without.During the study period there were 231 cases of cardiac arrest that occurred prior to EMS arrival eligible for police response in the study communities. Police were dispatched to 124 (54%) of these cases. Of the 124, the police arrived before EMS 37 times, or 16% of the 231 cases. Police performed CPR in 29 of these cases and applied the AED in 21 of them. Of the 21 cases in which the AED was applied for cardiac arrest, a shock was delivered on first analysis for 6 patients. Although the response interval between dispatch to scene arrival was similar for EMS and police (4.5 minutes versus 4.6 minutes respectively, p = 0.08), police were dispatched considerably slower than EMS (1.8 minutes versus 0.6 minutes, p < 0.001).In the current programmatic implementation, police had a measurable but limited involvement in resuscitation. Efforts to address dispatch challenges may improve police involvement.
