Dispatcher-Assisted CPR: An Intervention Whose Time Has Come
Disclosure: Dr. Eisenberg has nothing to disclose.
Pub Date: Monday, February 25, 2013
Author: Mickey Eisenberg, MD, PhD
Affiliation: Albert Einstein College of Medicine, Montefiore-Einstein Medical Center
Sasson C, Meischke H, Abella BS, Berg RA, Bobrow BJ, Chan PS, Dowling Root E, Heisler M, Levy JH, Link M, Masoudi F, Ong M, Rumsfeld JS, Sayre MR, Rea TD; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, and Council on Cardiovascular Surgery and Anesthesia. Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders. Circulation. 2013: published online before print February 25, 2013, 10.1161/CIR.0b013e318288b4dd.
Among medical emergencies cardiac arrest is the most extreme. At the moment of collapse the pulse disappears and blood pressure falls to zero. The patient is clinically dead and the inexorable arrow of time is heading toward clinical death in a matter of minutes. Cardiopulmonary resuscitation (CPR) extends this narrow window of opportunity by adding a few extra minutes for EMS personnel to arrive and perform defibrillation and other advanced life support interventions. Though bystander CPR has the potential to save lives it is seldom performed in the prehospital setting. Community bystander CPR rates are low and vary considerably throughout North America (Sasson cites community bystander CPR rates of 10% to 65% with an average of 25%)1 and this in turn helps explain the low and disparate survival rates from out-of-hospital cardiac arrest. If EMS personnel could reach a collapsed person within 3 or 4 minutes of collapse, bystander CPR would not be necessary. But response times this short are not readily achieved. A report from the Resuscitation Outcomes Consortium reported an interquartile range of 7 minutes to 13 minutes from the call to first rhythm analysis.2 This does not take into account the dispatch center processing time or the call transfer time from a primary public safety answering point to the dispatching answering point. This unmeasured time is often 2 or more minutes. With these time intervals it is unlikely that anyone will survive cardiac arrest without bystander CPR. As medical director of a large EMS system I see daily the importance of CPR. Our system has a very high survival rate from cardiac arrest due to ventricular fibrillation and our bystander CPR rate (over 50%) is one major reason.
Sasson’s article lays out four critical steps toward achieving bystander CPR: there must be recognition of the cardiac arrest on the part of the bystander, 9-1-1 must be called promptly, the dispatcher must recognize cardiac arrest and rapidly dispatch EMS personnel, and finally CPR must begin either by the bystander who has been trained in CPR or as a result of dispatcher-assisted CPR instructions delivered over the phone. The authors describe strategies to increase bystander CPR and these include public education campaigns, use of non-traditional educational materials such as simple training manikins, web-based instruction, CPR mobile apps, and social media. They also endorse dispatcher-assisted CPR whereby emergency dispatchers are trained to recognize cardiac arrest and provide instant instructions over the phone in how to perform chest-compressions. Dispatcher-assisted CPR is termed “just in time” instruction that can “engage rescuers in emergency bystander CPR who have not been recently trained, do not immediately identify the cardiac arrest event, lack confidence, are panicked, or have cultural or linguistic barriers to performing CPR.” Sasson et al also argue convincingly for the use of data and information systems to identify at the macro level how a system is performing (in terms of bystander CPR and survival rates) and at the micro level (to pinpoint areas or neighborhoods needing more training or attention).
All of these strategies will undoubtedly help to a large or small degree and I would not discourage their promotion. However, the one that is not only the easiest to implement but will achieve the biggest results with the least expenditure of resources is dispatcher-assisted CPR. Vaillancourt in a review of the literature ranks dispatcher-assisted CPR as the top strategy to achieve bystander CPR.3 Since 1981, dispatcher-assisted CPR has been part of the EMS system in Seattle and King County. Today, even in the face of a high proportion of the local population trained in CPR, dispatcher instructions account for half of all bystander CPR. Written protocols provide guidance on adult, child, and infant CPR and there are also instructions for choking. Dispatchers receive special training in the recognition of cardiac arrest and how to identify agonal breathing. There is ongoing continuing education and recent revisions in our protocols provide special guidance for persons calling with limited English proficiency.
My colleagues and I host a Resuscitation Academy (resuscitationacademy.org) three times a year in Seattle. We attempt to provide attendees with the knowledge and tools to improve cardiac arrest survival in their own communities. We distill the message into a handful of steps, each likely to result in improved survival. We further characterize each step as low-hanging fruit or high-hanging fruit.4 Among the juiciest of the low-hanging fruits is dispatcher-assisted CPR. It does not require additional personnel or equipment (difficult to accomplish in these economic times), nor is the training very complex. We believe that a dispatcher can reach proficiency in as little as 4 hours of training. During the Academy classes we ask attendees if their systems offer dispatcher-assisted CPR and almost all reply in the affirmative. But with a little boring down it becomes apparent that instructions are rarely offered and there is no formal QI program to measure and improve performance. Their situation is representative of the national experience. Most dispatch centers report having a program in dispatcher-assisted CPR but few succeed in consistently delivering CPR instructions and even fewer have a rigorous QI program.
A quality dispatcher-assisted CPR program increases the rate of bystander CPR leading to an increase in cardiac arrest survival.5 To achieve this, there must be initial and ongoing training, an ongoing QI program in which every cardiac arrest call is reviewed, feedback given to the dispatchers, and defined metrics for success. We believe attainable metrics are recognition of cardiac arrest in 75% of all cardiac arrest calls, recognition of cardiac arrest within a median time of 60 seconds from call pick up, delivery of chest compressions in 50% of all cardiac arrest calls, and a median time to first compression of 120 seconds. We further argue that these metrics should become national standards for emergency dispatch centers and we call upon all emergency dispatch centers to embrace these standards.
I applaud Sasson and her co-authors, not only for placing a spotlight on the deplorable situation of bystander CPR, but also for drawing attention to the life-saving potential of dispatcher-assisted CPR. Dispatcher-assisted CPR is an intervention whose time has come. It should become a new standard of care throughout the nation.
- Sasson C, Meischke H, Abella BS, Berg RA, Bobrow BJ, Chan PS, Dowling Root E, Heisler M, Levy JH, Link M, Masoudi F, Ong M, Rumsfeld JS, Sayre MR, Rea TD; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, and Council on Cardiovascular Surgery and Anesthesia. Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders. Circulation. 2013: published online before print February 25, 2013, 10.1161/CIR.0b013e318288b4dd.
- Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.
- Vaillancourt C, Stiell IG, Wells GA, Understanding and improving low bystander CPR rates: a systematic review of the literature. CJEM 2008;10:51-65.
- Eisenberg MS, Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrest, 2nd Edition. University of Washington Press, Seattle, 2013
- Rea TD, Eisenberg MS, Culley L, Becker L. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation 2001;104:2513-2516.