Telecommunicator CPR Recommendations and Performance Measures

Sudden cardiac arrest (SCA) is the sudden, unexpected loss of heart function, breathing and consciousness, and is commonly the result of an electrical disturbance in the heart. Each year an estimated 350,000 cardiac arrest events occur in the United States in an out-of-hospital environment. Almost all of these events result in a call for help to 911. Without quick intervention in the form of cardiopulmonary resuscitation (CPR) and defibrillation, death from SCA is certain.

Telecommunicatorsare 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 telecommunicator 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.

Every emergency dispatch center in the nation should be aware of the following:

  • 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

Program Recommendations

  1. Commitment to T-CPR
    • The emergency communications center will commit to providing effective T-CPR.
    • The dispatch center director must provide leadership and hold the staff accountable for implementation
  2. Train and Provide Continuing Education in T-CPR for all Telecommunicators
    • Require initial training for 100% of call takers and dispatchers. Initial training will require an estimated 3-4 hours.
    • Require ongoing continuing education. This will require 2-3 hours annually.
  3. Conduct Ongoing Quality Improvement (QI) for all Calls in which a Cardiac Arrest is Confirmed by EMS Personnel and in which Resuscitation is Attempted
    • 100% of calls in which resuscitation is attempted must have the dispatch call audited for QI purposes.
    • The QI must collect key time intervals and reasons for non-recognition of cardiac arrest and reasons for delays.
    • Individual QI review of every cardiac arrest call provided by the supervisor (or designated QI person) including helpful feedback.
    • QI reports must be summarized annually and secular trends reported.
    • QI reports should be used to identify training needs.
  4. Connection to EMS Agency
    • Close engagement with the EMS agency is required to link data from dispatch audio with EMS run report data.
    • Linkage with EMS is required to identify the denominator of total cardiac arrest cases and the percentage of all cardiac arrests which are recognized as cardiac arrest by the telecommunicator/dispatcher.
  5. Designated Medical Director
    There must be a designated communications center medical director who shall issue the dispatch protocols for T-CPR and be able to work closely with the EMS agency. Ideally there should be a combined medical director for the dispatch center and EMS agency.
  6. Recognition for Outstanding Performance
    Telecommunicator recognition program for outstanding performance in the recognition of cardiac arrest and delivery of T-CPR instructions.

Performance Measures

  1. Percentage of Total OHCA Cases Correctly Identified by PSAP
    • Definition: Telecommunicator-recognized OHCAs/total OHCAs (confirmed by EMS impression)×100
    • Numerator: QI reviewed and EMS confirmed OHCAs with recognition noted
    • Denominator: Number of EMS-confirmed OHCAs
    • Performance goal: 75%
  2. Percentage of OHCA Cases Correctly Identified by PSAP That Were Recognizable

    The combination of the first 2 quality measures rewards telecommunicators for being as sensitive as possible at identifying OHCA (number 1) while allowing for real-world circumstances to inform reasonable expectations (number 2). The combined use of these 2 commitments prevents individual AHJs from “gaming” the system by being overly exclusionary while maximizing the number of true-positive OHCA identifications that receive T-CPR (Figure 2).

    Venn Diagram
    Figure 2. Composition of emergency medical services (EMS) calls for service that require quality assurance. OHCA indicates out-of-hospital cardiac arrest; and T-CPR, telecommunicator cardiopulmonary resuscitation.

  3. Percentage of Telecommunicator-Recognized OHCAs Receiving T-CPR
    • Definition: Number of telecommunicator-recognized OHCA cases receiving telecommunicator-directed T-CPR/number of telecommunicator-recognized OHCA cases×100
    • Numerator: Number of QI-reviewed, EMS-confirmed OHCAs with recognition noted when telecommunicator-directed T-CPR is performed
    • Denominator: Number of QI-reviewed, EMS-confirmed OHCAs with recognition noted
    • Performance goal: 75%
    • Exclusions from denominator
      • CPR is already in progress by lay rescuer
      • Caller is unable to physically perform CPR (eg, call being made from a different location than the OHCA)
      • Caller is unable to get the patient into the appropriate position for CPR (eg, cannot move patient from bed to floor)
      • Caller refuses to perform T-CPR
      • For safety, T-CPR instructions are not given (eg, traumatic cause, disaster scenario)
      • Caller hangs up
      • Other circumstances the supervisor deems valid for why T-CPR could not be performed
  4. Figure 3. Telecommunicator cardiopulmonary resuscitation (T-CPR) time interval standards. CPR indicates cardiopulmonary resuscitation; EMS, emergency medical services, and OHCA, out-of-hospital cardiac arrest. *These recommended performance intervals should be as short as possible and are provided to demonstrate minimal acceptable performance.

  5. Median Time Between 9-1-1 Call and OHCA Recognition
    • Definition: Median amount of time in seconds between 9-1-1 call connection and OHCA recognition
    • Benchmark: <90 Seconds from AHJ receiving the call to telecommunicator recognition of OHCA (Figure 3)
  6. Median Time Between 9-1-1 Call and First T-CPR–Directed Compression
    • Definition: Median amount of time in seconds between 9-1-1 call connection and first CPR compression directed by telecommunicator
    • Benchmark: <150 Seconds from AHJ receiving call to first CPR compression directed by telecommunicator (Figure 3)

The AHA acknowledges the following:

  • During the interval between AHJ receiving the transferred 9-1-1 and OHCA recognition, the call taker is also aware of the need to dispatch an appropriate medical response as rapidly as possible. In the triage script suggested above, an answer of “no” by the caller to either of the first questions (“Is the patient conscious?” or “Is the patient breathing normally?” [see the Call-Taking Process section in Operational Considerations for Implementation of a T-CPR Program]) should prompt immediate dispatch of resources appropriate to treat the highest priority call within the EMS system. Examples of other high-priority complaints identified by using the script other than a person with cardiac arrest include individuals with respiratory failure or shock and patients with altered mental status who are unconscious. Each of these patients would warrant EMS resources similar to a cardiac arrest to prevent further deterioration. Although those high-priority situations are specifically outside the scope of this statement, the writing group agrees that dispatching such EMS response should be done in parallel with recognition and should adhere to the same time-metric standard.
  • Performance goals 4 and 5 may be challenging to meet in the short-term because of PSAP call transfer protocols or other structural barriers that may lie outside the authority of the AHJ responsible for EMS dispatch.
  • Measurement of intervals before call transfer to the AHJ responsible for dispatching EMS should be included; however, when measurement is impractical, the minimum acceptable performance standard should apply. Standard 3 ensures that each identified person with OHCA receives T-CPR. The combination of standards 4 and 5 ensures that T-CPR is received as rapidly as possible.

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 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.

Telephone CPR (T-CPR)

Telecommunicators are the true, first responders and a critical link in the cardiac arrest chain of survival; a telecommunicator can make the difference between life and death.

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.