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.
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.
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
- 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
- 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.
- 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.
- 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.
- 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.
- Recognition for Outstanding Performance
- Telecommunicator recognition program for outstanding performance in the recognition of cardiac arrest and delivery of T-CPR instructions.
- Percentage of Total Out-of-Hospital Cardiac Arrest (OHCA) Cases Correctly Identified by Public Safety Answering Point (PSAP)
- Definition: telecommunicator recognized / total OHCA (confirmed by EMS impression)
- Numerator: # of QI reviewed EMS confirmed OHCA with recognition noted
- Denominator: EMS confirmed OHCA
- Performance Goal: 75%
- Percentage of OHCA Cases Correctly Identified by PSAP that were Recognizable
- Definition: telecommunicator recognized / number of cases deemed identifiable
- Numerator: number of QI reviewed EMS confirmed OHCA with recognition noted
- Denominator: number of QI reviewed EMS confirmed OHCA deemed identifiable by supervisor
- Exclusions from denominator:
- 3rd party calls
- Hang up
- CPR in progress
- Language barrier
- Other circumstances supervisor deems “unidentifiable”
- Performance Goal: 95%
- Percentage of Call-Taker Recognized OHCA Receiving T-CPR
- Definition: number of telecommunicator recognized OHCA cases receiving call-taker directed T-CPR / number of call-taker recognized OHCA cases
- Numerator: number of QI reviewed EMS confirmed OHCA with recognition noted where call-taker directed T-CPR is preformed
- Denominator: number of QI reviewed EMS confirmed OHCA with recognition noted
- Exclusions from denominator:
- CPR is already in progress by bystander
- Caller is unable to physically perform CPR (ie, call being made from alternative location to OHCA)
- Caller is unable to get patient into appropriate position for CPR (ie, can’t move patient from bed to floor)
- Call-taker refuses
- For safety, T-CPR instructions are not given (eg, traumatic cause, disaster scenario, etc.)
- Hang up
- Other circumstances supervisor deems T-CPR could not be performed
- Performance Goal: 75%
- Median Time Between 911 Call and OHCA Recognition
- Definition: median amount of time in seconds between 911 call connected and OHCA recognition
- Benchmark: < 120 seconds (less than 60 seconds from address acquisition to telecommunicator recognition of OHCA)
- We acknowledge:
- This performance goal may be challenging to meet in the short-term due to PSAP call transfer protocols that may lie outside the authority of the PSAP responsible for EMS dispatch.
- Measurement of intervals prior to call transfer to the PSAP responsible for dispatching EMS should be included, however where impractical, the minimal acceptable performance recommendation should revert to less than 60 seconds from address acquisition to telecommunicator recognition of OHCA.
- Median Time Between 911 Call and First T-CPR Directed Compression
- Definition: median amount of time in seconds between 911 call connected and first CPR compression directed by telecommunicator
- Benchmark: < 180 seconds (less than 120 seconds from address acquisition to first CPR compression directed by telecommunicator)
- We acknowledge:
- Measurement of intervals prior to call transfer to the PSAP responsible for dispatching EMS should be included, however where impractical, the minimal acceptable performance recommendation should revert to less than 120 seconds from address acquisition to first telecommunicator directed T-CPR compression.
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.