Telecommunicators are the true, first responders and a critical link in the cardiac arrest chain of survival. It is the telecommunicator, in partnership with the caller, who has the opportunity to identify a patient in cardiac arrest, providing the initial level of care by delivering telephone CPR (T-CPR) instructions to the caller, and quickly dispatching the appropriate level of help. It is through these actions that the telecommunicator can make the difference between life and death. It is important to emphasize that the telecommunicator and the caller form a unique team in which the expertise of the telecommunicator and the willingness of the caller to provide T-CPR represents the best opportunity to improve survival form SCA.
The information below outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions by emergency telecommunicators. Where possible, these processes should occur in parallel, rather than in series, to minimize the overall time interval from 911 call to T-CPR as much as possible.
- The provision of T-CPR instruction for virtually all cardiac arrests is a standard of care.
- Meeting this standard requires training, ongoing training, and continuous quality improvement.
- Meeting this standard saves lives.
- Not meeting this standard results in deaths that are preventable.
BARRIERS TO IMPLEMENTATION
Several system barriers can slow the implementation of telephone CPR (T-CPR) programs. These include, but are not limited to, a public safety answering point’s (PSAPs) chartered or perceived scope of practice, organizational culture, fear of liability, public relations concerns, and budget constraints.
Formal medical direction and supervision is essential. An active, engaged physician provides qualified oversight of emergency medical dispatch (EMD), the T-CPR protocol, and quality improvement practices. Through active involvement, the medical director can support and implement T-CPR programs by communicating their importance to elected public officials. Furthermore, they can educate local decision-makers to overcome the widely-held misconception that T-CPR instructions are beyond the scope of practice of the PSAP.
The provision of such instructions is, in fact, the standard of care vetted by experts in resuscitation science and practice. Providing T-CPR instructions is the single most effective method for improving bystander CPR rates. Furthermore, scientific investigations suggest adult patients who mistakenly receive chest compressions (ie, they are not in cardiac arrest) suffer injury only in 1 in 50 cases. Those injuries were all chest wall injuries and no internal organ injuries occurred. (See White et. al. Circulation 2009)
The authors of the current recommendations are unaware of any lawsuits filed against 911 centers in connection with T-CPR and suggest that 911 centers are more likely to face liability for not providing CPR instructions in cases of confirmed out-of-hospital cardiac arrest (OHCA). Furthermore, they suggest that concern of poor publicity from publicly released 911 recordings are vastly overstated in light of the very real benefits of providing T-CPR to OHCA victims.
Local budgets are a perennial barrier to quality-improvement practice. T-CPR process measurement is time- and labor-intensive. An accurate representation of call-taker performance, however, can be gleaned by evaluating a subset of OHCA calls. 911 centers must define a sustainable fraction of calls to evaluate through time to improve the quality of care they provide in their communities.