Barriers to dispatcher-assisted telephone cardiopulmonary resuscitation

Abstract

Most people who witness a person in cardiac arrest have not been trained in cardiopulmonary resuscitation (CPR).1Kellermann AL Hackman BB Somes G Dispatcher-assisted cardiopulmonary resuscitation: validation of efficacy.Circulation. 1989; 80: 1231-1239Crossref PubMed Scopus (85) Google Scholar The person most likely to witness a cardiac arrest event is a relative because most of these events occur in the home.2de Vreede Swagemakers JJM Gorgels APM Dubois-Arbouw WI et al.Out-of-hospital cardiac arrest in the 1990s: a population-based study in the Maastricht area on incidence, characteristics and survival.J Am Coll Cardiol. 1997; 30: 1500-1505Abstract Full Text Full Text PDF PubMed Scopus (677) Google Scholar Although a close relative is more willing to give CPR than a stranger, unfortunately, they often lack the knowledge to provide this life-saving intervention.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar, 4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google ScholarInvestigators demonstrated that one effective way to close this knowledge gap is to have emergency medical dispatchers who receive 911 calls give bystanders “on-the-spot” teaching in CPR over the telephone.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar Most victims who could benefit from dispatcher-assisted telephone instruction in CPR have their cardiac arrest at home.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar Of great importance, telephone CPR is associated with a 50% improvement in the odds of survival to hospital discharge compared with those who received no CPR before the arrival of emergency medical services (EMS).3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar However, even where a telephone CPR program is well-established, nearly one half of victims still do not receive CPR before the arrival of EMS.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google ScholarIn this issue of Annals, Hauff et al4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar present important information regarding barriers to implementation of telephone CPR. The investigators separated the reasons why dispatcher CPR instructions are not implemented into 3 main phases: (1) the dispatcher did not offer CPR instructions; (2) instructions were offered, but the caller declined to implement the instructions; and (3) instructions were offered and accepted, but CPR still was not given. The most frequent reason that cardiac arrest victims did not receive bystander CPR was because the victim was believed to have signs of life. In the first phase, CPR instructions were not given for 64% of patients with cardiac arrest because they were believed to have signs of life, most likely because of the presence of agonal respirations. On review of the dispatch tapes, in instances where the telephone was near the victim, agonal respirations were identified in 5/7 cases. In all 3 phases, 34% (56/166) of cardiac arrest patients did not receive CPR because they were thought to have signs of life. How can we improve this situation?Clearly, we need to have better ways to recognize when a person is in cardiac arrest. Very little research is available regarding recognition of signs of life, which now is a critical first step for the lay rescuer to initiate CPR. Investigators reported the presence of agonal respirations in as many as 55% of witnessed cardiac arrest victims.5Clark JJ Larsen MP Culley LL et al.Incidence of agonal respirations in sudden cardiac arrest.Ann Emerg Med. 1991; 21: 1464-1467Abstract Full Text PDF Scopus (182) Google Scholar, 6Bång A Herlitz J Martinell S 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.Resuscitation. 2003; 56: 25-34Abstract Full Text Full Text PDF PubMed Scopus (121) Google ScholarIt is also clear that the way dispatchers ask a question over the telephone is extremely important. For example, CPR was withheld inappropriately when dispatchers omitted such questions as “Is the person breathing normally?” or “Is the person awake and conscious?”6Bång A Herlitz J Martinell S 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.Resuscitation. 2003; 56: 25-34Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 7Hallstrom AP Dispatcher-assisted “phone” cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.Crit Care Med. 2000; 28: N190-N192Crossref PubMed Scopus (47) Google Scholar Thus, there are possible solutions that can be used to eliminate barriers for people to take action to increase the frequency of bystander CPR. Notably, emotional distress, concerns about disease transmission, disagreeable victim characteristics, or medicolegal concerns rarely impeded bystander CPR in the present study.Barriers to CPR and possible ways to eliminate them include:1.Signs of life, particularly agonal respirations, impede recognition of sudden cardiac arrest.In the 2000 revision of guidelines for CPR, the American Heart Association deleted using the pulse check for lay rescuers to initiate CPR and instead recommended using absence of “signs of life” or “signs of circulation” (ie, normal breathing, coughing, movement) as a signal to begin CPR.8American Heart Association in collaboration with International Liaison Committee on Resuscitation Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Part 3: Adult Basic Life Support.Circulation. 2000; 102: I22-I59PubMed Google Scholar The pulse check was deleted for lay rescuers because studies showed that rescuers require more than 24 seconds to decide whether a pulse is present, they miss the pulse when it is present in 4 of 10 times (poor specificity), and when victims were pulseless, rescuers thought a pulse was present 10% of the time (poor sensitivity).9Bahr J Klingler H Panzer W et al.Skills of lay people in checking the carotid pulse.Resuscitation. 1997; 35: 23-26Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar, 10Ochoa FJ Ramalle-Gomara E Carpintero JM et al.Competence of health professionals to check the carotid pulse.Resuscitation. 1998; 37: 173-175Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 11Flesche CW Neruda B Breuer S et al.Basic cardiopulmonary resuscitation skills: a comparison of ambulance staff and medical students in Germany.Resuscitation. 1994; 28: S25Google Scholar, 12Flesche CW Breuer S Mandel LP et al.The ability of health professionals to check the carotid pulse.Circulation. 1994; 90: 288Google Scholar, 13Eberle B Dick WF Schneider T et al.Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse.Resuscitation. 1996; 33: 107-116Abstract Full Text PDF PubMed Scopus (302) Google Scholar Signs of circulation replaced the pulse check for lay rescuers out of concern that CPR would be withheld inappropriately for 10 of 100 people who actually need CPR and because the accuracy of this sign is only 65%. Although the guidelines emphasize that lay rescuers should look for “normal breathing” to minimize confusion with agonal respirations, it appears that the presence of agonal respirations is a frequent cause for withholding CPR. Therefore, even more emphasis should be placed on the significance of agonal respirations when teaching signs of life and additional research is needed regarding the accuracy of this sign.In addition, assessment by dispatchers should be done in a carefully structured manner, such as asking “are they awake and conscious?” and “are they breathing normally?” If the bystander and the dispatcher are unsure about whether the person has signs of life, perhaps it would be wise to err on the side of caution and start CPR (the benefit of saving a life from cardiac arrest outweighs the risk of injury from chest compressions).2.Physical barriers/limitations.CPR was not initiated when the rescuer was unable to move or roll the victim who was sitting in a chair or lying in the prone position. Further research should be done on alternative CPR techniques that are feasible in such situations. For example, investigations show that administering chest compressions to the back can be effective while the patient is lying in the prone position.14Brown J Rogers J Soar J Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review.Resuscitation. 2001; 50: 233-238Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 15Sun WZ Huang FY Kung KL et al.Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.Anesthesiology. 1992; 77: 202-204Crossref PubMed Scopus (50) Google Scholar In addition, for those bystanders who are unable to perform chest compressions with the arms, using the foot for compressions is an alternative that may be effective.16Bilfield LH Regula GA A new technique for external heart compression.JAMA. 1978; 239: 2468-2469Crossref PubMed Scopus (10) Google Scholar3.Difficulty performing CPR.In the present study, a substantial number of bystanders accepted instructions but still did not initiate CPR, and it took dispatchers 2 minutes to give instructions for mouth-to-mouth ventilation alone. Ventilating a person with an unprotected airway is a far more complex psychomotor skill than chest compressions alone, which likely could be instructed over the telephone in a much shorter time. It is possible that more people would give chest compressions if ventilation were eliminated from telephone instructions. Therefore, EMS systems should consider the use of a chest compressions–only protocol, which has been used successfully in a large EMS system.17Hallstrom A Cobb L Johnson E et al.Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.N Engl J Med. 2000; 342: 1546-1553Crossref PubMed Scopus (463) Google Scholar The American Heart Association currently recommends chest compressions–only CPR “for use in dispatcher-assisted CPR instructions where the simplicity of this modified technique allows untrained bystanders to rapidly intervene (Class IIa).”18Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care International Consensus on Science.Circulation. 2000; 102: I-44Crossref Google ScholarEfforts should be made to increase bystander CPR frequency by implementing the following:1.More programs should be developed for dispatcher-assisted “on-the-spot” teaching over the telephone for bystanders, both untrained and as immediate refresher training for individuals with prior experience.2.Shorter and more accessible CPR courses should be available for businesses, neighborhoods, and schools.3.Public access automatic external defibrillator programs should be developed rationally for greater use in public places and not be limited to airports and casinos where the probability of being resuscitated from cardiac arrest and surviving is more than 50% compared with 3% to 5% in the home.19Zipes DP Saving time saves lives.Circulation. 2001; 104: 2506-2508PubMed Google Scholar4.The SAVE program (“Save a Victim Everywhere”) is based on 2 public initiatives—volunteer firemen and neighborhood watch associations.20Zipes DP President's page: the neighborhood heart watch program: Save A Victim Everywhere (SAVE).J Am Coll Cardiol. 2001; 37: 2004-2005Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Teams of neighbors trained in CPR could provide defibrillation with a strategically placed automated external defibrillator in less time than the EMS system.Hauff et al4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar have provided very valuable information and given us reason to be hopeful that survival from cardiac arrest can be improved. The solutions required are not insurmountable, are fairly uncomplicated, and are within our grasp. Further research is crucial to identify signs of cardiac arrest that bystanders and dispatchers can use reliably to guide action. Most people who witness a person in cardiac arrest have not been trained in cardiopulmonary resuscitation (CPR).1Kellermann AL Hackman BB Somes G Dispatcher-assisted cardiopulmonary resuscitation: validation of efficacy.Circulation. 1989; 80: 1231-1239Crossref PubMed Scopus (85) Google Scholar The person most likely to witness a cardiac arrest event is a relative because most of these events occur in the home.2de Vreede Swagemakers JJM Gorgels APM Dubois-Arbouw WI et al.Out-of-hospital cardiac arrest in the 1990s: a population-based study in the Maastricht area on incidence, characteristics and survival.J Am Coll Cardiol. 1997; 30: 1500-1505Abstract Full Text Full Text PDF PubMed Scopus (677) Google Scholar Although a close relative is more willing to give CPR than a stranger, unfortunately, they often lack the knowledge to provide this life-saving intervention.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar, 4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Investigators demonstrated that one effective way to close this knowledge gap is to have emergency medical dispatchers who receive 911 calls give bystanders “on-the-spot” teaching in CPR over the telephone.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar Most victims who could benefit from dispatcher-assisted telephone instruction in CPR have their cardiac arrest at home.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar Of great importance, telephone CPR is associated with a 50% improvement in the odds of survival to hospital discharge compared with those who received no CPR before the arrival of emergency medical services (EMS).3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar However, even where a telephone CPR program is well-established, nearly one half of victims still do not receive CPR before the arrival of EMS.3Rea TD Eisenberg MS Culley LL et al.Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest.Circulation. 2001; 104: 2513-2516Crossref PubMed Scopus (339) Google Scholar In this issue of Annals, Hauff et al4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar present important information regarding barriers to implementation of telephone CPR. The investigators separated the reasons why dispatcher CPR instructions are not implemented into 3 main phases: (1) the dispatcher did not offer CPR instructions; (2) instructions were offered, but the caller declined to implement the instructions; and (3) instructions were offered and accepted, but CPR still was not given. The most frequent reason that cardiac arrest victims did not receive bystander CPR was because the victim was believed to have signs of life. In the first phase, CPR instructions were not given for 64% of patients with cardiac arrest because they were believed to have signs of life, most likely because of the presence of agonal respirations. On review of the dispatch tapes, in instances where the telephone was near the victim, agonal respirations were identified in 5/7 cases. In all 3 phases, 34% (56/166) of cardiac arrest patients did not receive CPR because they were thought to have signs of life. How can we improve this situation? Clearly, we need to have better ways to recognize when a person is in cardiac arrest. Very little research is available regarding recognition of signs of life, which now is a critical first step for the lay rescuer to initiate CPR. Investigators reported the presence of agonal respirations in as many as 55% of witnessed cardiac arrest victims.5Clark JJ Larsen MP Culley LL et al.Incidence of agonal respirations in sudden cardiac arrest.Ann Emerg Med. 1991; 21: 1464-1467Abstract Full Text PDF Scopus (182) Google Scholar, 6Bång A Herlitz J Martinell S 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.Resuscitation. 2003; 56: 25-34Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar It is also clear that the way dispatchers ask a question over the telephone is extremely important. For example, CPR was withheld inappropriately when dispatchers omitted such questions as “Is the person breathing normally?” or “Is the person awake and conscious?”6Bång A Herlitz J Martinell S 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.Resuscitation. 2003; 56: 25-34Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 7Hallstrom AP Dispatcher-assisted “phone” cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.Crit Care Med. 2000; 28: N190-N192Crossref PubMed Scopus (47) Google Scholar Thus, there are possible solutions that can be used to eliminate barriers for people to take action to increase the frequency of bystander CPR. Notably, emotional distress, concerns about disease transmission, disagreeable victim characteristics, or medicolegal concerns rarely impeded bystander CPR in the present study. Barriers to CPR and possible ways to eliminate them include:1.Signs of life, particularly agonal respirations, impede recognition of sudden cardiac arrest.In the 2000 revision of guidelines for CPR, the American Heart Association deleted using the pulse check for lay rescuers to initiate CPR and instead recommended using absence of “signs of life” or “signs of circulation” (ie, normal breathing, coughing, movement) as a signal to begin CPR.8American Heart Association in collaboration with International Liaison Committee on Resuscitation Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Part 3: Adult Basic Life Support.Circulation. 2000; 102: I22-I59PubMed Google Scholar The pulse check was deleted for lay rescuers because studies showed that rescuers require more than 24 seconds to decide whether a pulse is present, they miss the pulse when it is present in 4 of 10 times (poor specificity), and when victims were pulseless, rescuers thought a pulse was present 10% of the time (poor sensitivity).9Bahr J Klingler H Panzer W et al.Skills of lay people in checking the carotid pulse.Resuscitation. 1997; 35: 23-26Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar, 10Ochoa FJ Ramalle-Gomara E Carpintero JM et al.Competence of health professionals to check the carotid pulse.Resuscitation. 1998; 37: 173-175Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 11Flesche CW Neruda B Breuer S et al.Basic cardiopulmonary resuscitation skills: a comparison of ambulance staff and medical students in Germany.Resuscitation. 1994; 28: S25Google Scholar, 12Flesche CW Breuer S Mandel LP et al.The ability of health professionals to check the carotid pulse.Circulation. 1994; 90: 288Google Scholar, 13Eberle B Dick WF Schneider T et al.Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse.Resuscitation. 1996; 33: 107-116Abstract Full Text PDF PubMed Scopus (302) Google Scholar Signs of circulation replaced the pulse check for lay rescuers out of concern that CPR would be withheld inappropriately for 10 of 100 people who actually need CPR and because the accuracy of this sign is only 65%. Although the guidelines emphasize that lay rescuers should look for “normal breathing” to minimize confusion with agonal respirations, it appears that the presence of agonal respirations is a frequent cause for withholding CPR. Therefore, even more emphasis should be placed on the significance of agonal respirations when teaching signs of life and additional research is needed regarding the accuracy of this sign.In addition, assessment by dispatchers should be done in a carefully structured manner, such as asking “are they awake and conscious?” and “are they breathing normally?” If the bystander and the dispatcher are unsure about whether the person has signs of life, perhaps it would be wise to err on the side of caution and start CPR (the benefit of saving a life from cardiac arrest outweighs the risk of injury from chest compressions).2.Physical barriers/limitations.CPR was not initiated when the rescuer was unable to move or roll the victim who was sitting in a chair or lying in the prone position. Further research should be done on alternative CPR techniques that are feasible in such situations. For example, investigations show that administering chest compressions to the back can be effective while the patient is lying in the prone position.14Brown J Rogers J Soar J Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review.Resuscitation. 2001; 50: 233-238Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 15Sun WZ Huang FY Kung KL et al.Successful cardiopulmonary resuscitation of two patients in the prone position using reversed precordial compression.Anesthesiology. 1992; 77: 202-204Crossref PubMed Scopus (50) Google Scholar In addition, for those bystanders who are unable to perform chest compressions with the arms, using the foot for compressions is an alternative that may be effective.16Bilfield LH Regula GA A new technique for external heart compression.JAMA. 1978; 239: 2468-2469Crossref PubMed Scopus (10) Google Scholar3.Difficulty performing CPR.In the present study, a substantial number of bystanders accepted instructions but still did not initiate CPR, and it took dispatchers 2 minutes to give instructions for mouth-to-mouth ventilation alone. Ventilating a person with an unprotected airway is a far more complex psychomotor skill than chest compressions alone, which likely could be instructed over the telephone in a much shorter time. It is possible that more people would give chest compressions if ventilation were eliminated from telephone instructions. Therefore, EMS systems should consider the use of a chest compressions–only protocol, which has been used successfully in a large EMS system.17Hallstrom A Cobb L Johnson E et al.Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.N Engl J Med. 2000; 342: 1546-1553Crossref PubMed Scopus (463) Google Scholar The American Heart Association currently recommends chest compressions–only CPR “for use in dispatcher-assisted CPR instructions where the simplicity of this modified technique allows untrained bystanders to rapidly intervene (Class IIa).”18Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care International Consensus on Science.Circulation. 2000; 102: I-44Crossref Google Scholar Efforts should be made to increase bystander CPR frequency by implementing the following:1.More programs should be developed for dispatcher-assisted “on-the-spot” teaching over the telephone for bystanders, both untrained and as immediate refresher training for individuals with prior experience.2.Shorter and more accessible CPR courses should be available for businesses, neighborhoods, and schools.3.Public access automatic external defibrillator programs should be developed rationally for greater use in public places and not be limited to airports and casinos where the probability of being resuscitated from cardiac arrest and surviving is more than 50% compared with 3% to 5% in the home.19Zipes DP Saving time saves lives.Circulation. 2001; 104: 2506-2508PubMed Google Scholar4.The SAVE program (“Save a Victim Everywhere”) is based on 2 public initiatives—volunteer firemen and neighborhood watch associations.20Zipes DP President's page: the neighborhood heart watch program: Save A Victim Everywhere (SAVE).J Am Coll Cardiol. 2001; 37: 2004-2005Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Teams of neighbors trained in CPR could provide defibrillation with a strategically placed automated external defibrillator in less time than the EMS system. Hauff et al4Hauff SR Rea TD Culley LL et al.Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation.Ann Emerg Med. 2003; 42: 731-737Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar have provided very valuable information and given us reason to be hopeful that survival from cardiac arrest can be improved. The solutions required are not insurmountable, are fairly uncomplicated, and are within our grasp. Further research is crucial to identify signs of cardiac arrest that bystanders and dispatchers can use reliably to guide action.