Dispatcher-assisted Cardiopulmonary Resuscitation Research Articles

Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition.

Video call based dispatcher-assisted cardiopulmonary resuscitation (V-DACPR) has been suggested to improve the quality of bystander cardiopulmonary resuscitation. In the current system, dispatchers must convert the audio calls to video calls to provide V-DACPR. We aimed to develop new audio call-to-video call transition protocols and test its efficacy and safety compared to conventional DACPR(C-DACPR). This was a randomized controlled simulation trial that compared the quality of bystander chest compression that was performed under three different DACPR protocols: C-DACPR, V-DACPR with rapid transition, and V-DACPR with delayed transition. Adult volunteers excluding healthcare providers were recruited for the trial. The primary outcome of the study was the mean proportion of adequate hand positioning during chest compression. Simulation results of 131 volunteers were analyzed. The mean proportion of adequate hand positioning was highest in V-DACPR with rapid transition (V-DACPR with rapid transition vs. C-DACPR: 92.7% vs. 82.4%, p=0.03). The mean chest compression depth was deeper in both V-DACPR groups than in the C-DACPR group (V-DACPR with rapid transition vs. C-DACPR: 40.7mm vs. 35.9mm, p=0.01, V-DACPR with delayed transition vs. C- DACPR: 40.9mm vs. 35.9mm, p=0.01). Improvement in the proportion of adequate hand positioning was observed in the V-DACPR groups (r=0.25, p<0.01 for rapid transition and r=0.19, p<0.01 for delayed transition). Participants in the V-DACPR groups performed higher quality chest compression with higher appropriate hand positioning and deeper compression depth compared to the C-DACPR group.

Improved Out-of-Hospital Cardiac Arrest Survival with a Comprehensive Dispatcher-Assisted CPR Program in a Developing Emergency Care System

Objective Out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Studies have demonstrated improved survival with early bystander cardiopulmonary resuscitation (BCPR). This study evaluated the impact of a dispatcher-assisted CPR (DA-CPR) program on BCPR rate and outcomes of OHCA in a developing emergency medical services (EMS) system setting. Methods Data were extracted from the national cardiac arrest registry. A before-after analysis was performed between OHCA cases with cardiac etiology conveyed by EMS from April 2010–June 2012 (pre-intervention) and July 2012–December 2015 (post-intervention). Primary outcomes were survival-to-discharge/30 days post-arrest and favorable cerebral performance (Glasgow-Pittsburgh cerebral performance categories 1 and 2). Results 6365 OHCA cases were analyzed with 2129 in the pre-intervention and 4236 in the post-intervention group. In the post-intervention group, there was an increase in BCPR rates from 24.8% to 53.8% (p < 0.001), adjusted OR 3.67 (aOR; 95%CI: 3.26–4.13). OHCA outcomes also improved with survival-to-discharge rates increasing from 3.0%–4.5% (p < 0.01), aOR 2.10 (95%CI: 1.40–3.17) and favorable cerebral performance increasing from 1.6% to 2.7% (p < 0.05), aOR 2.82 (95%CI: 1.65–4.82). In patients with initial shockable rhythm, BCPR without dispatcher assistance was associated with significantly higher odds of survival-to-discharge (aOR 1.67, 95%CI: 1.06–2.64) and favorable cerebral performance (aOR 2.32, 95%CI: 1.26–4.27) compared to no BCPR. Conclusion Our study showed that a simplified DA-CPR program can be successfully implemented in a developing EMS system and can contribute to higher BCPR rate and in turn, improve OHCA survival. Future studies can examine bystanders’ characteristics and quality of the CPR performed to understand their impact on survival.

Comparison between dispatcher-assisted bystander CPR and self-led bystander CPR in out-of-hospital cardiac arrest (OHCA)

IntroductionBystander cardiopulmonary resuscitation (CPR) is an important prognostic factor for outcome in out-of-hospital cardiac arrest (OHCA). The dispatcher-assisted (DA) bystander CPR program has increased the rate of bystander CPR by targeting bystanders with a lower level of CPR training. We evaluated the effects of dispatcher-assisted bystander CPR and self-led bystander CPR. MethodsA retrospective analysis was performed using a nationwide OHCA database from 2014 to 2018. Adult EMS-treated OHCA patients with presumed cardiac origin were enrolled. OHCAs were classified into 3 groups according to the type of bystander CPR (DA bystander CPR vs. self-led bystander CPR vs. no bystander CPR) provided. The primary outcome was good neurologic recovery at hospital discharge. A multivariable logistic regression model was used to estimate the association between the type of bystander CPR and outcomes. ResultsA total of 91,557 eligible OHCA patients was enrolled in the final analysis. The proportion of patients with favorable neurologic outcomes was highest with self-led bystander CPR (9.0% for self-led bystander CPR, 5.2% for DA bystander CPR and 3.2% for no bystander CPR, p < 0.01). Self-led bystander CPR was associated with better neurological recovery than DA bystander CPR (aOR with 95% CI (DA-CPR as reference): 0.63 (0.58−0.69) for no bystander CPR, 1.28 (1.17–1.40) for self-led bystander CPR). ConclusionAlthough DA CPR was associated with better neurologic outcomes than no bystander CPR, good neurologic outcomes were most strongly associated with self-led bystander CPR.

Abstract 250: Effect of Coaching on Dispatch-assisted Cardiopulmonary Resuscitation: A Randomized Simulation Study

Introduction: Immediate bystander cardiopulmonary resuscitation (CPR) is essential for the good outcome of sudden cardiac arrest victims. Current guidelines recommend dispatch-assisted CPR (DACPR). Its quality, however, varies from case to case. The aim of this study was todetermine the effectiveness of dispatch coaching on the quality of CPR by lay rescuers. Methods: We conducted a DACPR simulation study. Participants with no prior CPR training within 1 year were assigned randomly to one of two DACPR simulations (No Coaching Group: callers were told to perform CPR and the dispatcher sometimes confirmed if the caller was performing CPR or Coaching Group: the dispatcher coached, encouraged, and counted out loud with a metronome). The study participants performed CPR for 2 minutes under the study dispatcher. All performances were recorded by video camera and Resusci Anne® QCPR (Laerdal, Norway). Results: Forty-nine participants aged 20s to 50s were recruited, and 48 completed the simulation (Coaching Group, 27, 9 males and No Coaching Group, 21, 16 males). The average rate of chest compressions was 102.5/min in Coaching Group and 109.3/min in No Coaching group (p=0.270). The average compression depth was slightly deeper in Coaching group (43.0mm vs 41.5mm, p=0.695). When compared the average depth of the first 10 compressions to the total average in each group, the depth significantly improved in Coaching group while that decreased in No Coaching Groups (38.4mm to 43.0mm; p=0.020, 42.3mm to 41.5mm; p=0.431, respectively). The chest compression fraction was also high in Coaching Group (99.4% vs 93.0%, p=0.005). Conclusions: Participants in Coaching Group performed better CPR compared to No Coaching Group in terms of high flow fraction. Although the average compression depth was below the guideline recommendation in both groups, it significantly improved in Coaching group. This study indicates that dispatch coaching can optimize the performance of bystander CPR.

Abstract 245: Dispatcher Assisted Cardiopulmonary Resuscitation in Patients Not in Cardiac Arrest: A Multi-Center, Observation Study

Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Protocols used by dispatchers are designed to provide a quick assessment for prompt initiation of CPR. However, there are instances where non-cardiac arrest cases are falsely recognised by dispatchers to be in cardiac arrest. These patients may go on to receive chest compressions and potentially suffer from complications of unnecessary CPR, though the clinical implications of starting DA-CPR on these non-cardiac arrest cases have not been studied. Hence, the objectives of this study are to find the prevalence and clinical outcomes of DA-CPR in patients not in cardiac arrest in the Singapore population. Methods: This was a multi-center, observational study of all dispatcher-recognized cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was collected through audio review of dispatch calls from the national emergency ambulance service and information about patients’ clinical outcomes were prospectively collected from health records. Results: During the study period, dispatchers recognised 821 patients as having cardiac arrest. Of these, 40.0% (328/ 821) were not in cardiac arrest. 52.7% (173/ 328) of the non-cardiac arrest patients had chest compressions initiated under dispatcher assistance. No complications from chest compressions were reported. The top diagnoses of non-cardiac arrest patients found were cerebrovascular accidents (CVA), syncope and infection. A multiple logistic regression model with estimates adjusted for the presence or absence of chest compressions revealed that only final diagnoses of CVA (OR 20.68), infection (OR 17.34) and myocardial infarction (OR 32.19) were associated with in-hospital mortality. Conclusion: In this study, chest compressions initiated due to false recognition of cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Abstract 251: Characterizing Bystanders and Their Actions in Response to Out of Hospital Cardiac Arrest

Background: Bystander actions upon witnessing a cardiac arrest are crucial to improving patient survival. Bystander perceptions and actions when witnessing a cardiac arrest are complex and not well understood. Our study has three primary aims: 1) To characterize CA bystanders demographics, 2) To understand the events from patient collapse until EMS arrival, with a focus on telecommunicator or dispatcher-assisted CPR (T-CPR), and 3) Bystander knowledge/ training in CPR and their actions at the time of CA. Methods: This is a prospective observational study conducted on bystanders of out of hospital cardiac arrests (OHCA) serviced by EMS agencies in southeast Michigan. OHCA patients were identified from 3/2018- 12/2019, and bystanders of these events surveyed. Surveys were mailed to non-medical addresses with an introductory letter and paper survey. A phone interview was conducted to describe bystander demographics, events from collapse to EMS arrival, and their actions including CPR performance. We inquired regarding telecommunicator CPR instructions (T-CPR), and if CPR was not performed what were the barriers. Results: During our study period, 126 surveys were mailed, and of these 47 bystander surveys were completed. The majority of events occurred in private homes (37/47,78.7%). Few patients (10, 21.2%) survived to discharge. The bystander and patient age were (mean, range)were 62.9 (30-91 ) and 69.3 (30-100) respectively. The majority were female 27/47(57.4%), most 43/47 (91.4%) knew the patient and were family (34/47,72.3%). Bystanders knew the patient a median(range) of 32 (0-68) years. A majority of bystanders (31/47,66.0%) had CPR training and 19 performed CPR. Of the 14/47 (27.8%) that received T-CPR instructions, 9 performed CPR. CPR trained bystanders that did not perform CPR(8/31), identified panic, assessment barriers and physical reasons for not performing CPR. Conclusion: In this preliminary work, we identify that bystanders to OHCA are most often family, of similar age to the patient and knew the patient for decades. CPR educational programs should prepare trainees to know that they may well respond to loved ones. Further researcher characterizing bystanders and their actions are needed to improve cardiac arrest outcomes.

Effects of positive dispatcher encouragement on the maintenance of bystander cardiopulmonary resuscitation quality.

Background: Implementation of dispatcher-assisted cardiopulmonary resuscitation (DACPR) has increased the likelihood of bystander CPR upon cardiac arrest. However, the quality of CPR has been found to be very low. In this study, we aimed to compare CPR quality between the current DACPR practices and the interventional instruction of adding verbal encouragement from the dispatcher.Methods: In this randomized controlled trial, we recruited adult (age ≥18) laypersons who were non-health care providers and had never received any previous verified CPR training. They were randomly selected to perform DACPR using metronome sounds (mDACPR) as per the standard protocol, or DACPR with metronome sounds along with human encouragement (mheDACPR). The ratio of accurate compression rate, depth, and complete release for each CPR phase was examined.Results:Sixty nine records (34, mDACPR; 35, mheDACPR) were taken. The median proportion of accurate chest compression rate was initially 29.5% with mDACPR, and significantly increased to 71% after 2 minutes of CPR administration (P = .046). However, the median ratio of accurate chest compression depth was 61.5% in the first phase, and significantly decreased to 0% in the last phase (P < .001). In contrast, for the mheDACPR group, a high accurate compression rate was maintained throughout the 2 minutes of CPR administration (91%, 100%, 100%, 100%).Conclusion: To maintain the quality of CPR administered by bystanders, continuous feedback and repeated human encouragement should be provided during DACPR. Active dispatcher intervention reduces the time required to reach an appropriate CPR rate and allows for the maintenance of accurate compression rates.

The impacts on bystander and dispatcher-assisted cardiopulmonary resuscitation during COVID-19 pandemic

Purpose: The impact of emerging infections disease pandemic such as COVID-19 on bystander CPR performance is not well known Materials-and-methods: This was an observational database prospectively collected from National Registry for DACPR (dispatcher-assisted CPR), a continuous quality control for OHCA by audio records analyses of EMS calls The performance of DACPR before and after the COVID-19 epidemic was compared among four individual EMS systems (three metropolitan and one suburban) The bystander chest compressions (BCC) rate prior to the call, successful delivery of BCC after dispatcher-assisted, and the continuity of CC until hand-over by the paramedics after arrival (HCC) as the categorical indicators, and the operational time interval corresponding to call-to-compression were evaluated and analyzed using Pearson's chi-squared test, Independent t-test, and Kruskal–Wallis test with SPSS Version 22 Results: In a total of 3263 eligible patients from four EMS systems, for patients already receiving BCC prior to the call, though showing a tendency of decrease, there were no significant differences after the epidemics (A: 3 6% vs 5 7%, p = 0 13;B: 4 5% vs 6 1%, p = 0 46;C: 6 0% vs 6 6%, p = 0 71;D: 6 8% vs 10 7%, p = 0 59;Total: 4 9% vs 6 4%, p = 0 11) For dispatcher-assisted BCC delivery, a metropolitan (B) significantly decreased and the suburban (D) significantly increased (A: 55 0% vs 56 1%, p = 0 72;B: 41 8% vs 52 3%, p = 0 03;C: 60 6% vs 56 5%, p = 0 19;D: 83 0% vs 60 2%, p < 0 01;Total: 56 8% vs 55 6%, p = 0 53) For continuity of HCC, a metropolitan(C) and the suburban (D) both significantly increased as well as the total cases (A: 43 9% vs 46 4%, p = 0 43;B: 28 5% vs 31 0%, p = 0 56;C: 54 0% vs 40 0%, p < 0 01;D: 77 4% vs 59 3%, p = 0 02;Total: 47 4%vs 41 3%, p < 0 01) For call-to-compression interval, all regions showed a tendency to be faster without significance (A: 185 vs 189 s, p = 0 8;B: 141 vs 156 s, p = 0 19;C: 173 vs 182 s, p = 0 12;D: 156 vs 171 s, p = 0 27;Total: 164 vs 172 s, p = 0 19) Conclusions: The impacts of COVID-19 pandemic showed a tendency to decrease BCC prior to dispatcher-assisted, and were significantly varied for dispatcher-assisted BCC among different EMS systems, however the timely BCC would not be delayed Continuity of BCC even significantly increased under the national continuous auditing

The adherence to modified callers queries (MCQ) of emergency medical dispatch (EMD) during COVID-19 outbreaks for out-of-hospital cardiac arrest

Purpose: Setting modified-callers-queries (MCQ) was recommended for emergency medical dispatch (EMD) for COVID-19 risks screening during the outbreaks. For out-of-hospital cardiac arrest calls, the adherence to MCQ and its influence to dispatcher-assisted CPR were not known.

When dispatcher assistance is not saving lives: assessment of process compliance, barriers and outcomes in out-of-hospital cardiac arrest in a metropolitan city in China

BackgroundSeveral Chinese cities have implemented dispatcher-assisted cardiopulmonary resuscitation (DA-CPR), although out-of-hospital cardiac arrest (OHCA) survival rates remain low. We aimed to assess the process compliance, barriers and outcomes of OHCA...

Quality of dispatcher-assisted vs. automated external defibrillator-guided cardiopulmonary resuscitation: a randomised simulation trial

Quality of hands-only cardiopulmonary resuscitation (CPR) is an important determinant of resuscitation outcome for cardiac arrest patients cared for by lay rescuers. We designed a simulation trial to assess and compare the quality of CPR among untrained lay people under two different scenarios: automated external defibrillator (AED)-guided and dispatcher-assisted CPR. A simulation study was performed involving 42 volunteers selected by non-probabilistic sampling. Participants were randomized into two CPR simulation scenarios with a manikin: (A) AED-guided CPR and (T) dispatcher-assisted CPR. The quality of CPR was evaluated by metric monitoring of the chest compressions and timing of actions. Content analysis of the telephone instructions was performed by two independent researchers using a checklist. CPR was started in 20 of the 21 cases in scenario A and in all cases in scenario T. In total, 12 053 chest compressions were applied, 57.6% corresponding to scenario A. The proportion of compressions that were of an adequate depth was low in both cases, 15.3% in scenario A vs. 31.7% in scenario T (P < 0.001), while complete chest recoil was allowed in 66 and 72% (P < 0.001) of compressions, respectively. The AED advised to shock 91 times, and shocks were delivered in all cases. Although guided CPR helps untrained people to initiate resuscitation manoeuvres, the quality of CPR was poor in both groups. Telephone guidance improved the proportion of compressions that achieved adequate chest compression and recoil but did not optimise the compression rate.

Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest

AimStrategies to increase provision of bystander CPR include mass education of laypersons. Additionally, programs directed at emergency dispatchers to provide CPR instructions during emergency calls to untrained bystanders have emerged. The aim of this study was to evaluate the association between dispatcher-assisted CPR (DA- CPR) and 30-day survival compared with no CPR or spontaneously initiated CPR by lay bystanders prior to emergency medical services in out of hospital cardiac arrest (OHCA). MethodsNationwide observational cohort study including all consecutive lay bystander witnessed OHCAs reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010–2017. Exposure was categorized as: no CPR (NO-CPR), DA-CPR and spontaneously initiated CPR (SP-CPR) prior to EMS arrival. Propensity-score matched cohorts were used for comparison between groups. Main Outcome was 30-day survival. ResultsA total of 15 471 patients were included and distributed as follows: NO-CPR 6440 (41.6%), DA-CPR 4793 (31.0%) and SP-CPR 4238 (27.4%). Survival rates to 30 days were 7.1%, 13.0% and 18.3%, respectively. In propensity-score matched analysis (DA-CPR as reference), NO-CPR was associated with lower survival (conditional OR 0.61, 95% CI 0.52–0.72) and SP-CPR was associated with higher survival (conditional OR 1.21 (95% CI 1.05–1.39). ConclusionsDA-CPR was associated with a higher survival compared with NO-CPR. However, DA-CPR was associated with a lower survival compared with SP-CPR. These results reinforce the vital role of DA-CPR, although continuous efforts to disseminate CPR training must be considered a top priority if survival after out of hospital cardiac arrest is to continue to increase.

In out-of-hospital cardiac arrest, is the positioning of victims by bystanders adequate for CPR? A cohort study.

ObjectivesOutcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome.DesignProspective observational cohort study.SettingMetropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest.ParticipantsBystanders of all OHCAs occurring during a 12-month period (July 2006–July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included.Primary and secondary outcome measuresProportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months.ResultsPositioning of victims at EMS arrival was ‘supine on firm surface’ in 64 cases (32.0%), ‘recovery position (RP)’ in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when ‘supine position’ had been applied, 13.5% with ‘RP’ and 6.1% with ‘other positions unsuitable for CCs’; a statistically significant association could not be shown (p=0.740, Fisher’s exact test). However, after ‘effective CCs’ favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02).ConclusionIn OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.

&lt;p&gt;Telephone CPR: Current Status, Challenges, and Future Perspectives&lt;/p&gt;

With each successive update of the cardiopulmonary resuscitation (CPR) guidelines, the role of dispatchers in sudden cardiac arrest (CA) has grown. Dispatchers instruct callers in how to perform CPR until the arrival of emergency medical service (EMS) professionals. This is widely known as telephone CPR (TCPR) or dispatch-assisted CPR (DACPR). Studies have shown the efficacy of TCPR in increasing the survival rate of sudden CA. The TCPR process, however, is challenging and needs to be constantly evaluated and refined in order to improve the survival rate of sudden CA victims throughout the world. In this review article, the current status, challenges, and future perspectives of TCPR are discussed with a view to providing a research foundation from which to launch further studies into the effective role of dispatchers in sudden CA.

Is your unconscious patient in cardiac arrest? A New protocol for telephonic diagnosis by emergency medical call-takers: A national study

BackgroundWorldwide, call-taker recognition of out-of-hospital cardiac arrests (CA) suffers from poor accuracy, leading to missed opportunities for dispatcher-assisted cardiopulmonary resuscitation (DACPR) in CA patients and inappropriate DACPR in non-CA patients. Diagnostic protocols typically ask 2 questions in sequence: ‘Is the patient conscious?’ and ‘Is the patient breathing normally?’ As part of quality improvement efforts, our national emergency medical call centre changed the breathing question to an instruction for callers to place their hand onto the patient's abdomen to evaluate for the presence of breathing. MethodsWe performed a prospective before-and-after study of all unconscious cases from the national call centre database over a 31-day period in 2018. Cases were placed in 2 groups: 1) ‘Before’ group (standard protocol) where call-takers asked ‘Is the patient breathing normally?’ and 2) ‘After’ group (modified protocol) where callers were instructed to place their hand on the patient’s abdomen. In an intention-to-treat analysis, the accuracy, sensitivity and specificity of both protocols for determining CA were compared. Results1557 calls presented with unconsciousness, of which 513 cases were included. 231 cases were in the ‘Before’ group and 282 cases were in the ‘After’ group. The ‘After’ showed superior accuracy (84.4% vs 67.5%), sensitivity (75.0% vs 40.4%) and specificity (87.9% vs 75.4%) when compared to the standard protocol. Adherence in the ‘Before’ group to the standard protocol was 100%. However, adherence in the ‘After’ group to the modified protocol was 50.4%. Per protocol analysis comparing the modified protocol with the standard protocol showed vastly improved accuracy (96.5% vs 69.3%), sensitivity (94.1% vs 39.0%) and specificity (97.8% vs 77.2%) of the modified protocol. In patients with true cardiac arrest, the median time to 1st compression was 32.5 s longer in the modified protocol group when compared to the standard protocol group, approaching significance (199.5 s vs 167.0 s, p = 0.059). Median time to recognize CA was similar in both groups. ConclusionDispatch assessment using the hand on abdomen method appeared feasible but uptake by dispatch staff was moderate. Diagnostic performance of this method should be verified in randomised trials.

Impact of bystander-focused public health interventions on cardiopulmonary resuscitation and survival: a cohort study

Bystander cardiopulmonary resuscitation (CPR) increases an individual's chance of survival from out-of-hospital cardiac arrest (OHCA), but the frequency of bystander CPR is low in many communities. We aimed to assess the cumulative effect of CPR-targeted public health interventions in Singapore, which were incrementally introduced between 2012 and 2016. We did a secondary analysis of a prospective cohort study of adult, non-traumatic OHCAs, through the Singapore registry. National interventions introduced during this time included emergency services interventions, as well as dispatch-assisted CPR (introduced on July 1, 2012), a training programme for CPR and automated external defibrillators (April 1, 2014), and a first responder mobile application (myResponder; April 17, 2015). Using multilevel mixed-effects logistic regression, we modelled the likelihood of receiving bystander CPR with the increasing number of interventions, accounting for year as a random effect. The Singapore registry contained 11 465 OHCA events between Jan 1, 2011, and Dec 31, 2016. Paediatric arrests, arrests witnessed by emergency medical services, and healthcare-facility arrests were excluded, and 6788 events were analysed. Bystander CPR was administered in 3248 (48%) of 6788 events. Compared with no intervention, likelihood of bystander CPR was not significantly altered by the addition of emergency medical services interventions (odds ratio [OR] 1·33 [95% CI 0·98-1·79]; p=0·065), but increased with implementation of dispatch-assisted CPR (3·72 [2·84-4·88]; p<0·0001), with addition of the CPR and automated external defibrillator training programme (6·16 [4·66-8·14]; p<0·0001), and with addition of the myResponder application (7·66 [5·85-10·03]; p<0·0001). Survival to hospital discharge increased after the addition of all interventions, compared with no intervention (OR 3·10 [95% CI 1·53-6·26]; p<0·0001). National bystander-focused public health interventions were associated with an increased likelihood of bystander CPR, and an increased survival to hospital discharge. Understanding the combined impact of public health interventions might improve strategies to increase the likelihood of bystander CPR, and inform targeted initiatives to improve survival from OHCA. National Medical Research Council, Clinician Scientist Award, Singapore and Ministry of Health, Health Services Research Grant, Singapore.

Analysis of dispatcher-assisted cardiopulmonary resuscitation instructions to laypersons in an out-of-hospital cardiac arrest

Randomized simulation trial to analyze dispatcher-assisted cardiopulmonary resuscitation instructions provided from the emergency call center in an out-of-hospital heart arrest assisted by lay persons. An analysis of the telephone instructions was performed using a 14-item checklist by two external researchers. Simulations lasted nine minutes. Twenty-one volunteers were enrolled. All of them started resuscitation maneuvers. Telephone instructions were verbalized in very heterogeneous ways. Half of the indicators exceeded 90% compliance. Frequently the recommendation of push hard and fast on the patient's chest was omitted and the dispatcher tended to mark a slower compression rate. The average time from the call to the start of the resuscitation was 3 min 33 s (SD: 1 min 7 s). The telephone instructions were verbalized in a very heterogeneous way. It is necessary to standardize and provide training in how to guide a dispatcher-assisted resuscitation.

Assessment of Community Interventions for Bystander Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest

Outcomes from out-of-hospital cardiac arrests (OHCAs) remain poor. Outcomes associated with community interventions that address bystander cardiopulmonary resuscitation (CPR) remain unclear and need further study. To examine community interventions and their association with bystander CPR and survival after OHCA. Literature search of the MEDLINE, Embase, and the Cochrane Library databases from database inception to December 31, 2018, was conducted. Key search terms included cardiopulmonary resuscitation, layperson, basic life support, education, cardiac arrest, and survival. Community intervention studies that reported on comparisons with control and differences in survival following OHCA were included. Studies that focused only on in-hospital interventions, patients with in-hospital cardiac arrest, only dispatcher-assisted CPR, or provision of automated external defibrillators were excluded. Pooled odds ratios (ORs) and 95% CIs were estimated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Thirty-day survival or survival to hospital discharge and bystander CPR rate. A total of 4480 articles were identified; of these, 15 studies were included for analysis. There were broadly 2 types of interventions: community intervention alone (5 studies) and community intervention combined with changes in health services (10 studies). Four studies involved notification systems that alerted trained lay bystanders to the location of the OHCA in addition to CPR skills training. Meta-analysis of 9 studies including 21 266 patients with OHCA found that community interventions were associated with increased survival to discharge or 30-day survival (OR, 1.34; 95% CI, 1.14-1.57; I2 = 33%) and greater bystander CPR rate (OR, 1.28; 95% CI, 1.06-1.54; I2 = 82%). Compared with community intervention alone, community plus health service intervention was associated with a greater bystander CPR rate compared with community alone (community plus intervention: OR, 1.74; 95% CI, 1.26-2.40 vs community alone: OR, 1.06; 95% CI, 0.85-1.31) (P = .01). Survival rate, however, was not significantly different between intervention types: community plus health service intervention OR, 1.71; 95% CI, 1.09-2.68 vs community only OR, 1.26; 95% CI, 1.05-1.50 (P = .21). In this study, while the evidence base is limited, community-based interventions with a focus on improving bystander CPR appeared to be associated with improved survival following OHCA. Further evaluations in diverse settings are needed to enable widespread implementation of such interventions.

Sustaining improvement of dispatcher-assisted cardiopulmonary resuscitation for out-of-hospital cardiac arrest patients in Japan: An observational study

ObjectivesWe aimed to estimate the relationship between the promotion of bystander cardiopulmonary resuscitation (CPR) with dispatcher-assistance over time and good cerebral function after out-of-hospital cardiac arrests (OHCAs). MethodsThis was a retrospective observational study, using a nationwide OHCA database in Japan. The eligible 267,193 witnessed cardiogenic OHCA patients between 2005 and 2016 were analysed. Multivariable logistic regression models were performed to estimate the effect of dispatcher-assisted bystander CPR per year. In addition, we calculated the number of patients with good cerebral function, which was attributed to dispatcher-assisted bystander CPR. ResultsDispatcher-assisted bystander CPR was performed to 84,076 (31.5%), those without dispatcher-assistance were 48,389 (18.1%), and non-bystander CPR were 134,728 (50.4%). The adjusted odds ratio (AOR) of dispatcher-assisted bystander CPR vs. non-bystander CPR was significantly related to good cerebral function, regardless of the year (AOR, 1.47, 1.62; 95%CI, 1.19-1.80, 1.42-1.85, 2005 and 2016, respectively). The association of dispatcher-assisted bystander CPR with good cerebral function tended to increase (AOR, 1.11, 2.97; 95%CI, 0.99-1.24, 2.69-3.28, 2006 and 2016, based on 2005, respectively). Estimating the number of patients with good cerebral function who attributed to dispatcher-assisted bystander CPR was a significant increase from 41 in 2005 to 580 in 2016 (p < .0001, r = 0.98). Furthermore, chest compression consistently contributed to higher number of patients with good cerebral function than that with a combination of chest compression and shock with public-access-defibrillation. ConclusionWe found that the increased dispatcher-assisted bystander CPR rate was related to good cerebral function at 1-month post OHCA. Chest compression without public-access-defibrillation was most helpful to that number, explaining the effects of dispatcher-assistance and sustaining improvement.

The Effectiveness of a New Dispatcher-Assisted Basic Life Support Training Program on Quality in Cardiopulmonary Resuscitation Performance During Training and Willingness to Perform Bystander Cardiopulmonary Resuscitation: A Cluster Randomized Controlled Study.

A new dispatcher-assisted basic life support training program, called "Home Education and Resuscitation Outcome Study (HEROS)" was developed with a goal to provide high-quality dispatcher-assisted cardiopulmonary resuscitation (CPR) training, with a focus on untrained home bystanders. This study aimed to determine whether the HEROS program is associated with improved quality in CPR performance during training and willingness to provide bystander CPR compared with other basic life support programs without dispatcher-assisted CPR (non-HEROS). This clustered randomized trial was conducted in 3 district health centers in Seoul. Intervention group was trained with the HEROS program and control group was trained with non-HEROS program. The primary outcome was overall CPR quality, measured as total CPR score. Secondary outcomes were other CPR quality parameters including average compression depth and rate, percentages of adequate depth, and acceptable release. Tertiary outcomes were posttraining survey results. Difference in difference analysis was performed to analyze the outcomes. Among total 1929 trainees, 907 (47.0%) were trained with HEROS program. Compared with the non-HEROS group, the HEROS group showed higher-quality CPR performances and better maintenance of their CPR quality throughout the course (total scores of 84% vs. 80% for first session and 72% vs. 67% for last session; difference in difference of 12.2 vs. 13.2). Other individual CPR parameters also showed significantly higher quality in the HEROS group. The posttraining survey showed that both groups were highly willing to perform bystander CPR (91.4% in the HEROS vs. 92.3% in the non-HEROS) with only 3.4% of respondents in the HEROS group were not willing to volunteer compared with 6.2% in the non-HEROS group (P < 0.01). The HEROS training program helped trainees perform high-quality CPR throughout the course and enhanced their willingness to provide bystander CPR.