Public Safety Answering Point Recommendations

9-1-1 and public safety telecommunicators are a vital member of any EMS system, and they are a critical link in the cardiac arrest chain of survival. High performing communication centers who are able to provide a rapid assessment and quickly initiate Telecommunicator CPR (T-CPR) instructions positively impact cardiac arrest survival.

Adopting the American Heart Association’s T-CPR recommendations demonstrates your agency’s commitment to your community, and recognition of your role in cardiac arrest survival. [Program Recommendation #1: Commitment to T-CPR]

The information you find here will help you in your efforts to establish and maintain a high performing T-CPR program in your center, realizing your objective of improving cardiac arrest survival in your community.

You can also find links to additional tools and information on the T-CPR Resources page.

Path to Recommendation Compliance

The cardiac arrest chain of survival is centered around one key theme: Early access. This is why public safety communication centers and telecommunicators play such a critical role in cardiac arrest survival.

The more efficient the process for identifying a patient in cardiac arrest, beginning telephone CPR instructions, and dispatching resources, the greater the chance a patient will survive a cardiac emergency. One of the keys to quickly identifying a patient in cardiac arrest, as well as achieving compliance with the American Heart Association T-CPR performance recommendations, lays in your centers EMD program.

Additional Information

EMD Protocols

There are several commercial off the shelf EMD programs available on the market, such as the APCO EMD program, Medical Priority Dispatch System (MPDS), and PowerPhone 911, that communication centers may employ as a tool for triaging medical emergencies and for providing emergency pre-arrival instructions, including telephone CPR instructions. In addition to these commercially available programs, some agencies choose to develop their own “home grown” program under the guidance and authority of their jurisdiction’s Medical Director. [Program Recommendation #5: Designated Medical Director]

Regardless of the EMD program you use, it is important that your protocols allow for telecommunciators to quickly identify a patient in cardiac arrest, and to quickly move into telephone CPR instructions without delay. This process does not need to be complex nor lengthy, and can be accomplished by asking two key questions:

Is the patient conscious? Is the patient breathing normally?

Consciousness Assessment

Once the incident location is obtained, the telecommunicator should immediately begin the triage process, starting with determining if the patient is conscious. It must be recognized that “conscious” is a term that not all callers may be familiar with. While your EMD protocols may serve as a script for your call takers, they also must have the ability to adapt to the circumstances of the call and be allowed to use alternative terminology, such as “is the patient awake?”, “does the patient respond to you when you talk to them or touch them?” in order to obtain this information when appropriate.

Breathing Assessment

If the patient is reported as unconscious and is not breathing normally, T-CPR instructions should be initiated without delay.

EMD protocols for cardiac arrest identification do not need to be complex or lengthy. The simpler the process, the faster recognition will occur and telephone CPR instructions can begin.

Additional Considerations

Rapid (Accelerated) Dispatch

How much information must your call takers obtain in order to create a call for service? How long is it currently taking for the first units to be assigned to a call?  Once the call taker has verified the address where help is needed, and it is a known medical call, or it is reported to you that the patient is unconscious, you have sufficient information to initiate a call for service and dispatch medical aid.

Training & Implementation

Telecommunicators from around the country come from a variety of backgrounds with different levels of education and experience. Regardless of whether your center is staffed by sworn personnel with extensive medical training, or a civilian center where employees may have very limited medical knowledge; your agency is capable of meeting these American Heart Association T-CPR Performance Recommendations.

Regardless of your employee’s experience or background, 3-4 hours of initial training on T-CPR, as well as 2-3 hours of annual continuing education related to T-CPR and cardiac arrest, should be provided to all telecommunicators. [Program Recommendation #2: Train and Provide Continuing Education in T-CPR for all Telecommunicators]

Additional Information

Topics To Be Considered In Initial Training

• Anatomy & physiology of the circulatory and cardiovascular system
• Relationship between circulatory, respiratory, and nervous system
• Signs and symptoms of acute coronary syndrome (ACS)
• Signs of life recognition
• Early recognition of the need for CPR (Conscious/Breathing normally)
• Agonal respirations
• Hypoxic seizures and sudden cardiac arrest
• Pathophysiology of sudden cardiac death/cardiac arrest
• The role of T-CPR in cardiac arrest survival
• The importance of minimizing disruptions when T-CPR is in progress
• Physiology behind the performance of the instructions
• AEDs and the role they play in resuscitation
• Explanation, with practical training exercises, for different T-CPR instructions, including:
  • Adult
  • Child
  • Infant
  • Neonate
  • Pregnant patients
  • Obese patients
  • Stoma patients

Your quality improvement process is the greatest resource you have to identify current performance deficiencies, and to inform you development of annual continuing education.

Additional Topics

Additional topics to consider as part of your on-going continuing education program includes:

• Critical Incident Stress Management
• Unusual circumstances posing challenges to the delivery of T-CPR instructions, such as:
  • Patients with DNR orders
  • Patients on ventilators
  • Post-op patients
  • Obvious DOA
  • Electrocution
  • Drowning
  • Strangulation
  • Two rescuers- ventilations
  • Cardiac arrest from trauma
  • DNR/POLST orders

Opportunities

As much as possible, opportunities for hands-on, practical application of training should be provided, with emphasis on appropriate workflow, which is:

1. Verify address
2. Dispatch EMS response as soon as it is clear the call is for a medical emergency
3. Begin cardiac arrest assessment:
   • Is the patient conscious?
     • If NO
     • Are they breathing normally?
       • If NO
         • GO WITH CPR INSTRUCTIONS WITHOUT DELAY

Your training program is only limited by your creativity. Remember, not all training needs to be conducted off the floor and in a classroom. Providing your employees access to online videos, articles, written scenarios, and even EMS ride-along opportunities will help further their development and understanding of cardiac arrest and the role they play in survival.

Quality Improvement & Recognition

Your Quality Improvement program will help your center:

• Ensure compliance with training and established performance goals.
• Identify ongoing and future training needs.
• Reduce liability exposure by proactively identifying and remediating performance deficiencies.
• Identify exemplary performance for purposes of recognition.

Additional Information

Program Design

As you design your Quality Improvement process, there are some key questions you will need to answer:

• What will we evaluate?
• Who will perform the evaluations?
• How will we identify calls for review?
• How frequently will we provide feedback and reports?
• How will we recognize exemplary performance?

Evaluation Elements

The primary focus of your T-CPR QI should be all calls in which:

1. Cardiac arrest is confirmed by EMS personnel
2. Resuscitation is attempted. [Program Recommendation #3: Conduct Ongoing QI]

100% of calls in which resuscitation is attempted should be included in your review.

When performing T-CPR QI, key evaluation data collection points include:

1. Percentage of total Out-of-Hospital Cardiac Arrest (OHCA) cases correctly identified by the PSAP. Performance Goal: 75% [Performance Recommendation #1] 
2. Percentage of OHCA cases correctly identified by PSAP that were recognizable. Performance Goal: 95% [Performance recommendation #2] 
3. Percentage of call taker recognized OHCA receiving T-CPR. Performance Goal 75% [Performance recommendation #3]
4. Median time between 911 call and OHCA recognition [Performance Recommendation #4]
   • Benchmark time: <90 seconds (less than 90 second from address acquisition to first CPR compression directed by telecommunicator)
5. Median time between 911 call and first T-CPR directed compression [Performance Recommendation #5]
   • Benchmark time: <120 seconds (less than 120 second from address acquisition to first CPR compression directed by telecommunicator)

Special Considerations

There are times when telecommunicators will miss identifying a patient in arrest, or they may not get to the point of delivering T-CPR instructions to a caller. Sometimes, the reasons for this are outside of the telecommunicators control. When collecting data, it is important that we distinguish between those calls not meeting the performance recommendations due to circumstances outside of the telecommunicators control. These calls should be excluded from the denominator under performance recommendation #3.

Prior to conducting your first QI review, telecommunicators should be provided training on evaluation practices, including performance expectations, standards, and benchmarks.

Evaluators

Who will perform T-CPR QI reviews in your agency? Whomever you designate for this duty, your evaluators must possess an understanding of T-CPR protocols, as well as established performance standards and expectations.

Role of Supervisors

Supervisors are in the unique position of providing real-time feedback to telecommunicators by live monitoring T-CPR calls. This provides for immediate feedback to telecommunciators that will reinforce desired behaviors, and provide training and correction when necessary.

Call Identification

How will you identify CPR calls for review? Depending upon your CAD system, you may accomplish this by searching by:

• Problem nature/Call type
• IDC/Dispatch determinant code
• Closing/Disposition code

All T-CPR QI reviews should include review of CAD records and 9-1-1 audio.

Note, not all calls that come in to a PSAP as cardiac arrest truly are. Communication centers should partner with their EMS agencies to determine how to identify those calls that were truly cardiac arrest. [Program Recommendation #4]

Review and Report Frequency

100% of call in which T-CPR instructions were attempted should be reviewed.

In some centers, telecommunicators process over 100 calls for service per month. The more timely feedback is provided, the greater the chance the telecommunicator will remember the call, thus the more effective the feedback will be.

Telecommunicators should be provided with a written T-CPR QI review for all calls identified as cardiac arrest, or where CPR instructions were provided. Additionally, audio of calls should also be included as part of the QI documentation. Whenever possible, feedback should be provided in a one-on-one setting so that the telecommunicator may have an opportunity to ask questions and seek clarification about feedback.

Performance trend reports should be produces on a monthly basis to monitor for trends, track improvement, and to ensure compliance with performance recommendations. These reports should be made available to communication center personnel as well as local and regional stake holders.

Recognition

Telecommunicators are part of the EMS team, playing a critical role in cardiac arrest survival. T-CPR calls can be stressful and emotionally draining for a telecommunicator. The reality is that no every call will have a successful outcome, so it’s important that we celebrate those times when there is. Recognition can take many forms, from a certificate of achievement, a lanyard pin, or a challenge coin. You are really only limited by your imagination! Recognition will not only reinforce correct behaviors, but it will also motivate your work group to continue to grow and improve.