Micah Panczyk

Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes After Out-of-Hospital Cardiac Arrest

IMPORTANCE Bystander cardiopulmonary resuscitation (CPR) significantly improves survival from out-of-hospital cardiac arrest but is provided in less than half of events on average. Telephone CPR (TCPR) can significantly increase bystander CPR rates and improve clinical outcomes. OBJECTIVE To investigate the effect of a TCPR bundle of care on TCPR process measures and outcomes. DESIGN, SETTING, AND PARTICIPANTS A prospective, before-after, observational study of adult patients with out-of-hospital cardiac arrest not receiving bystander CPR before the 9-1-1 call between October 1, 2010, and September 30, 2013. INTERVENTIONS A TCPR program, including guideline-based protocols, telecommunicator training, data collection, and feedback, in 2 regional dispatch centers servicing metropolitan Phoenix, Arizona. Audio recordings of out-of-hospital cardiac arrest calls were audited and linked with emergency medical services and hospital outcome data. MAIN OUTCOMES AND MEASURES Survival to hospital discharge and functional outcome at hospital discharge. RESULTS There were 2334 out-of-hospital cardiac arrests (798 phase 1 [P1] and 1536 phase 2 [P2]) in the study group; 64% (1499) were male, and the median age was 63 years (age range, 9-101 years; interquartile range, 51-75 years). Provision of TCPR increased from 43.5% in P1 to 52.8% in P2 (P < .001), yielding an increase of 9.3% (95% CI, 4.9%-13.8%). The median time to first chest compression decreased from 256 seconds in P1 to 212 seconds in P2 (P < .001). All rhythm survival was significantly higher in P2 (184 of 1536 [12.0%]) compared with P1 (73 of 798 [9.1%]), with an adjusted odds ratio (aOR) of 1.47 (95% CI, 1.08-2.02; P = .02) in a logistic regression model and an adjusted difference in absolute survival rates (adjusted rate difference) of 3.1% (95% CI, 1.5%-4.9%). Survival for patients with a shockable initial rhythm significantly improved in P2 (107 of 306 [35.0%]) compared with P1 (42 of 170 [24.7%]), with an aOR of 1.70 (95% CI, 1.09-2.65; P = .02) and an adjusted rate difference of 9.6% (95% CI, 4.8%-14.4%). The rate of favorable functional outcome was significantly higher in P2 (127 of 1536 [8.3%]; 95% CI, 6.9%-9.8%) than in P1 (45 of 798 [5.6%]; 95% CI, 4.1%-7.5%), with an aOR of 1.68 (95% CI, 1.13-2.48; P = .01) and an adjusted rate difference of 2.7% (95% CI, 1.3%-4.4%). CONCLUSIONS AND RELEVANCE Implementation of a guideline-based TCPR bundle of care was independently associated with significant improvements in the provision and timeliness of TCPR, survival to hospital discharge, and survival with favorable functional outcome.

Dispatch-assisted cardiopulmonary resuscitation: the anchor link in the chain of survival.

Purpose of reviewEarly bystander cardiopulmonary resuscitation (CPR) provides a vital bridge after collapse from cardiac arrest until defibrillation can be performed. However, due to multiple barriers and despite large-scale public CPR training, this life-saving therapy is still not rendered in a majority of cardiac arrest events. As a result, cardiac arrest survival remains very low in most communities. Recent findingsSeveral large-scale studies have shown the benefits of dispatch-assisted CPR. These studies have confirmed that on-going dispatch-assisted CPR programs that use a simplified and abbreviated set of standardized questions can hasten the recognition of cardiac arrest. Dispatchers can also utilize strategies to help bystanders overcome the obstacles to beginning CPR. In some communities, dispatch-assisted CPR accounts for up to half of all bystander CPR. Dispatch-assisted CPR programs combined with large-scale public CPR training may be what is needed to elevate CPR rates and survival from out-of-hospital cardiac arrest nationally. SummaryThis review focuses on the rationale and evolving science behind dispatch CPR instructions, as well as some best practices for implementing and measuring dispatch-assisted CPR with the goal of maximizing its potential to save lives from sudden cardiac arrest.

Barriers to telephone cardiopulmonary resuscitation in public and residential locations.

AIM Emergency medical telecommunicators can play a key role in improving outcomes from out-of-hospital cardiac arrest (OHCA) by providing instructions for cardiopulmonary resuscitation (CPR) to callers. Telecommunicators, however, frequently encounter barriers that obstruct the Telephone CPR (TCPR) process. The nature and frequency of these barriers in public and residential locations have not been well investigated. The aim of this study is to identify the barriers to TCPR in public and residential locations. METHODS We conducted a retrospective study of audio recordings of EMS-confirmed OHCAs from eight regional 9-1-1 dispatch centers between January 2012 and December 2013. RESULTS We reviewed 1850 eligible cases (public location OHCAs: N=223 and residential location OHCAs: N=1627). Telecommunicators less frequently encountered barriers such as inability to calm callers in public than in residential locations (2.1% vs 8.5%, p=0.002) or inability to place victims on a hard flat surface (13.9% vs 25.4%, p<0.001). However, the barrier where callers were not with patients was more frequently observed in public than in residential locations (11.8% vs 2.7%, p<0.001). CONCLUSIONS This study revealed that barriers to TCPR are distributed differently across public and residential locations. Understanding these differences can aid in the development of strategies to enhance bystander CPR and improve overall patient outcomes.

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest

AIM OF STUDY This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies. METHODS We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group). RESULTS In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR. CONCLUSION TCPR is independently associated with improved survival and improved functional outcome after OHCA.

Telephone CPR Instructions in Emergency Dispatch Systems: Qualitative Survey of 911 Call Centers.

Introduction Out-of-hospital cardiac arrest (OHCA) is a leading cause of death. The 2010 American Heart Association Emergency Cardiovascular Care (ECC) Guidelines recognize emergency dispatch as an integral component of emergency medical service response to OHCA and call for all dispatchers to be trained to provide telephone cardiopulmonary resuscitation (T-CPR) pre-arrival instructions. To begin to measure and improve this critical intervention, this study describes a nationwide survey of public safety answering points (PSAPs) focusing on the current practices and resources available to provide T-CPR to callers with the overall goal of improving survival from OHCA. Methods We conducted this survey in 2010, identifying 5,686 PSAPs; 3,555 had valid e-mail addresses and were contacted. Each received a preliminary e-mail announcing the survey, an e-mail with a link to the survey, and up to three follow-up e-mails for non-responders. The survey contained 23 primary questions with sub-questions depending on the response selected. Results Of the 5,686 identified PSAPs in the United States, 3,555 (63%) received the survey, with 1,924/3,555 (54%) responding. Nearly all were public agencies (n=1,888, 98%). Eight hundred seventy-eight (46%) responding agencies reported that they provide no instructions for medical emergencies, and 273 (14%) reported that they are unable to transfer callers to another facility to provide T-CPR. Of the 1,924 respondents, 975 (51%) reported that they provide pre-arrival instructions for OHCA: 67 (3%) provide compression-only CPR instructions, 699 (36%) reported traditional CPR instructions (chest compressions with rescue breathing), 166 (9%) reported some other instructions incorporating ventilations and compressions, and 92 (5%) did not specify the type of instructions provided. A validation follow up showed no substantial difference in the provision of instructions for OHCA by non-responders to the survey. Conclusion This is the first large-scale, nationwide assessment of the practices of PSAPs in the United States regarding T-CPR for OHCA. These data showing that nearly half of the nation’s PSAPs do not provide T-CPR for OHCA, and very few PSAPs provide compression-only instructions, suggest that there is significant potential to improve the implementation of this critical link in the chain of survival for OHCA.

The Institute of Medicine Says Time to Act to Improve Cardiac Arrest Survival: Here’s How

It will happen hundreds of times today in our country: an ambulance, lights and sirens blaring, will race someone who experiences an out-of-hospital cardiac arrest to the closest emergency department (ED), where emergency physicians will expend intensive resources and often attempt heroic efforts to save a life; 94% of these patients will die. Despite decades of basic and clinical research, scientific guidelines, and widespread public and professional cardiopulmonary resuscitation (CPR) training requirements, the trajectory of survival has not improved appreciably. The bleak survival rates in most places foster a sense of helplessness and fatalism. In addition, many incorrectly believe that most cardiac arrest survivors experience poor functional outcomes. In fact, the majority of survivors are not neurologically devastated and go on to enjoy a good quality of life. A coordinated system-of-care approach with continuous quality improvement measures does work, as evidenced by the emergency medical services (EMS) system in Seattle/King County, WA, where survival from witnessed ventricular fibrillation cardiac arrest was 62% in 2014. Yet massive (up to 5-fold) variations in survival across communities in North America demonstrate unacceptable disparities between cities. The success of the HeartRescue Project, in which communities across the country have adopted this system-of-care approach with a commitment to implementing quality interventions long before patients reach our EDs, underscores the potential. The Institute of Medicine (IOM) recently issued recommendations to optimize cardiac arrest care in a study titled “Strategies to Improve Cardiac Arrest Survival: A Time to Act” (http://iom.nationalacademies.org/Reports/ 2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx). The report confirms that, as a nation, we are falling far short in our efforts to elevate survival. We believe there are 3 concrete high-yield interventions that will improve cardiac arrest survival in any community. Without these specific interventions fully deployed, cardiac

Barriers to patient positioning for telephone cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BACKGROUND 9-1-1 callers often face barriers preventing them from starting Telephone CPR (TCPR). The most common problem is getting patients to a hard, flat surface. This study describes barriers callers report when trying to move patients to a hard, flat surface and assesses conditions associated with overcoming these barriers. METHODS We audited 2396 out-of-hospital cardiac arrest (OHCA) audio recordings. A barrier was defined as any statement by the caller that the rescuer could not move the patient to the ground and into a supine position. Barriers were recorded and TCPR process metrics compared across the barrier and non-barrier groups. RESULTS There were 802 OHCAs in the study group. Roughly 26% had a barrier. Telecommunicators were less likely to start TCPR instructions in the barrier group than in the non-barrier group (OR: 0.63, 95% CI: 0.45-0.88; p=0.007). Telecommunicator-directed bystander chest compressions were more than twice as likely to start in the non-barrier group (OR: 2.2, 95% CI: 1.6-3.2; p<0.001). Median time to first compression was longer in the barrier group (276s vs 171s; p<0.001). Rescuers were 3.7 times more likely to overcome a barrier and start compressions (OR: 3.7, 95% CI: 2.0-6.8; p<0.001) when multiple bystanders were present. CONCLUSION Inability to move patients to a hard, flat surface is associated with a reduced rate of TCPR and increased time to first compression. Assessing the conditions under which such barriers are overcome is important for telecommunicator training and can help improve rates and timeliness of TCPR.

Disparities in telephone CPR access and timing during out-of-hospital cardiac arrest

AIM Spanish-only speaking residents in the United States face barriers to receiving potentially life-saving 911 interventions such as Telephone -cardiopulmonary resuscitation (TCPR) instructions. Since 2015, 911 dispatchers have placed an increased emphasis on rapid identification of potential cardiac arrest. The purpose of this study was to describe the utilization and timing of the 911 system during suspected out-of-hospital cardiac arrest (OHCA) by Spanish-speaking callers in Metropolitan Phoenix, Arizona. METHODS The dataset consisted of suspected OHCA from 911 centers from October 10, 2010 through December 31, 2013. Review of audio TCPR process data included whether the need for CPR was recognized by telecommunicators, whether CPR instructions were provided, and the time elements from call receipt to initiation of compressions. RESULTS A total of 3398 calls were made to 911 for suspected OHCA where CPR was indicated. A total of 39 (1.2%) were determined to have a Spanish language barrier. This averages to 18 calls per year with a Spanish language barrier during the study period, compared with 286 OHCAs expected per year among this population. The average time until telecommunicators recognized CPR need was 87.4s for the no language barrier group compared to 160.6s for the Spanish-language barrier group (p<0.001).Time to CPR instructions started was significantly different between these groups (144.4s vs 231.3s, respectively) (p<0.001), as was time to first compression, (174.4s vs. 290.9s, respectively) (p<0.001). CONCLUSIONS Our study suggests that Hispanic callers under-utilize the 911 system, and when they do call 911, there are significant delays in initiating CPR.

Telecommunicator CPR: Pushing for Performance Standards

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death and major global public health problem. There are an estimated 155,000 emergency medical services (EMS)-treated OHCAs in the United States annually.1 The estimated number of yearly EMSassessed OHCAs is 424,000.2 National survival rates have been stagnant for decades3 despite gains in our understanding of EMS factors affecting survival and neurologic outcome and the fundamental role prearrival cardiopulmonary resuscitation (CPR) plays in optimizing all subsequent EMS therapies. EMS systems respond to a wide array of medical emergencies, but none as time critical as cardiac arrest. Regrettably, the likelihood of surviving cardiac arrest varies widely among communities.4 While numerous system factors can be extremely difficult to modify, communities with the highest rates of bystander CPR consistently demonstrate the best survival rates. Bystander CPR is a powerful intervention and more than doubles the chance an OHCA patient survives to hospital discharge.3 Yet despite large-scale

Description of Abnormal Breathing Is Associated With Improved Outcomes and Delayed Telephone Cardiopulmonary Resuscitation Instructions

Background Emergency 9‐1‐1 callers use a wide range of terms to describe abnormal breathing in persons with out‐of‐hospital cardiac arrest (OHCA). These breathing descriptors can obstruct the telephone cardiopulmonary resuscitation (CPR) process. Methods and Results We conducted an observational study of emergency call audio recordings linked to confirmed OHCAs in a statewide Utstein‐style database. Breathing descriptors fell into 1 of 8 groups (eg, gasping, snoring). We divided the study population into groups with and without descriptors for abnormal breathing to investigate the impact of these descriptors on patient outcomes and telephone CPR process. Callers used descriptors in 459 of 2411 cases (19.0%) between October 1, 2010, and December 31, 2014. Survival outcome was better when the caller used a breathing descriptor (19.6% versus 8.8%, P<0.0001), with an odds ratio of 1.63 (95% confidence interval, 1.17–2.25). After exclusions, 379 of 459 cases were eligible for process analysis. When callers described abnormal breathing, the rates of telecommunicator OHCA recognition, CPR instruction, and telephone CPR were lower than when callers did not use a breathing descriptor (79.7% versus 93.0%, P<0.0001; 65.4% versus 72.5%, P=0.0078; and 60.2% versus 66.9%, P=0.0123, respectively). The time interval between call receipt and OHCA recognition was longer when the caller used a breathing descriptor (118.5 versus 73.5 seconds, P<0.0001). Conclusions Descriptors of abnormal breathing are associated with improved outcomes but also with delays in the identification of OHCA. Familiarizing telecommunicators with these descriptors may improve the telephone CPR process including OHCA recognition for patients with increased probability of survival.