How to Make the Most of Your Dispatch CPR Instructions

When a cardiac arrest happens, fast CPR can help save a life. That’s not in dispute, but the evidence still mounts: A 2015 New England Journal of Medicine review of more than 30,000 cases from Sweden, where around three million people are CPR-trained, found that 30-day survival was 10.5% when CPR was performed before EMS arrival and just 4.0% when it wasn’t.¹ “The positive correlation between early CPR and survival rate,” concluded the authors, “remained stable over the course of the study period.”

That’s not an isolated finding; other recent data from Denmark showed that after a sustained decade-long effort to improve bystander CPR rates (increasing the national rate from 21.1% to 44.9%), 30-day and one-year cardiac arrest survival tripled.²

So why don’t more than roughly a quarter of out-of-hospital SCA victims get bystander CPR? Generally we know those answers too; lack of knowledge and lack of confidence are large among them. And part of the remedy for both is a robust program of dispatch-assisted CPR instructions given to those who call 9-1-1 for cardiac arrest victims.

“We believe the earliest links in the chain of survival are most impactful for out-of-hospital arrest, and certainly bystander CPR is one of the most impactful interventions we can do to save lives,” says Ben Bobrow, MD, medical director for the Arizona Department of Health Services’ Bureau of Emergency Medicine and Trauma Services and past chair of the American Heart Association’s Basic Life Support Subcommittee. “What we now believe is that having the 9-1-1 call act as a mechanism to strengthen the bystander CPR link is incredibly important and is probably the underpinning of success in some of the communities across the country that have saved the most lives.”

If that’s so, what goes in to what they’re doing, and how can others emulate that success?

Aspects of Excellence

To be the best, learn from the best: Seattle and King County, WA, have long been among America’s leaders in cardiac arrest survival. While there are numerous reasons behind that, a prominent one is this: Cardiac arrest is a default assumption.

Not for all callers, of course. But if you collapse in those jurisdictions and aren’t conscious and breathing normally when a bystander calls 9-1-1, you will be getting compressions started.

“What they probably do better than anyone is consider every 9-1-1 call a cardiac arrest/potential CPR call until proven otherwise,” says Bobrow. “In most places, when 9-1-1 dispatchers answer the phone, they aren’t thinking, This is a CPR call. It sort of has to be proven to them that the person’s really in cardiac arrest. They have to ask about breathing, and the type of breathing, and often they’ll listen to the breathing, and still they’ll wonder, Do they really have cardiac arrest? But in Seattle and King County, if you’re unconscious or unresponsive and not breathing normally, you’re getting CPR started right away, and they’ll figure the rest out later. That’s a big paradigm shift in the way this is done from most cities around the country.”

So compression instructions generally get started faster. But not all instructions are equal. Even when given fast, they can come with a wide disparity in quality based on aspects like the dispatcher’s experience, confidence and ability to galvanize action from sometimes-reluctant rescuers.

The dispatch profession’s best can engage and calm jittery callers, establishing rapport and gaining the trust that helps get their directions followed. When compressions begin they’ll count along, help minimize pauses, remind to push hard and allow full recoil. They’ll keep spirits up through the compressor’s fatigue and gut-twisting wait for the pros. That ongoing coaching is also a component of success.

One key to it is experience.

“Most dispatchers, when they go on duty, aren’t thinking, Today I really want to take care of someone in cardiac arrest and have to get someone to do bystander CPR,” notes Bobrow. “So of course they’re reticent to do it—they don’t want to hurt anybody. If you don’t do this a lot, you can have some indecision; maybe you’re not as confident in what you’re saying and listening to. But confidence comes with practice and experience, and really confident telecommunicators can hear certain things: They listen for gasping on the telephone. They can tell by the tone of someone’s voice if a victim is in really bad shape and sounds like someone who really needs CPR. They get very skilled at these things and confident in their ability to get a caller calmed down. Because it’s very stressful, understandably, and if people are panicked, I think that’s the most common reason callers can’t get CPR started.”

Another component of CPR dispatch-instruction excellence is measurement. That means every aspect of the process: not only how often instructions are given and how often callers actually perform CPR, but metrics like time from call reception to recognition of potenial OHCA, and then to the start of instructions and then compressions.

Ultimately the most important measure is the duration from call reception to the start of actual compressions.

“You can look at two different cases in two different cities, and they may both have gotten CPR started,” says Bobrow. “But in one city maybe that took 90 seconds, and in the other maybe it took seven minutes. We think that’s part of the disparity in outcomes among communities.”

There’s more that goes into it beyond that, too; obviously the proper rate and depth of compressions are vital, as is minimizing pauses. A dispatcher that really gets it can help a caller can make a huge difference in all those areas.

Breathing Normally

At December’s Emergency Cardiovascular Care Update show in San Diego, where Bobrow and other top docs spoke on this and related matters, there was a lot of talk about gasping—the agonal breaths that can lead a bystander/caller to give an incorrect answer to a dispatcher’s inquiry about whether a patient is breathing.

Abnormal breathing is something we can listen for, rather than just quiz the caller about. It’s usually not subtle and often discernible. And when we ask about it, how we do so matters a lot.

“If you ask a caller ‘Are they breathing?’ they’ll look down and see someone taking these agonal gasps, and they’ll say ‘Yeah, sort of,’” Bobrow says. “But if you ask them, ‘Are they breathing normally?’, they’ll look down and tell you, ‘No, that’s not normal breathing. I don’t know what that is, but that’s not normal breathing. That’s the way my fish breathes when he falls out of the fishbowl.’”

Normally is an important adverb, and recent changes to the American Heart Association’s CPR and Emergency Cardiovascular Care guidelines underline it:

“To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim’s absence of responsiveness and quality of breathing (normal versus not normal),” the AHA’s document highlighting the revisions says. “If the victim is unresponsive with absent or abnormal breathing, the rescuer and dispatcher should assume the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and descriptions.”³ 

The why behind this further suggests dispatchers be specifically educated to help bystanders recognize that agonal gasps are a sign of cardiac arrest and ask “straightforward” questions about normal/abnormal breathing.
“Often, if you just ask whether they’re breathing, the caller will answer yes when they’re gasping,” says Bobrow. “Then the next move for some dispatchers is, ‘OK, turn them on their side in a recovery position, and help is on the way.’ We just missed an opportunity to help that person!

“I think that situation happens all the time. Hopefully less and less as we go along, but I still think a lot of times we miss the opportunity to give prearrival CPR instructions because we confuse gasping with breathing normally.”

It All Matters

A final best practice is to harness the power of social media. A specific way is by use of something like the PulsePoint app, through which dispatch systems can alert CPR-trained bystanders to nearby cardiac arrests. This lets them get quickly to those victims’ sides and get compressions started. It also tells them where to find the closest AED.

“I really think there’s enormous potential to use social media to basically make the public become the first responders,” says Bobrow. “That’s really what we want, and certainly we can do it better than we have in the past. We know social media and using smartphones and things like the PulsePoint app can help us locate able and willing rescuers and connect them to cardiac arrest victims.”

We don’t know on a grand scale how beneficial that is or might become, though there seems potential. But it’s worth noting—and this is true of even the best dispatch CPR instructions as well—that there is no single magic bullet to improving survival from out-of-hospital cardiac arrest. Having such weapons in isolation isn’t likely to do much. But as part of a larger system—which includes aware citizens, lots of AEDs, short call intervals, fast EMS response and good hospital and post-arrest care—they can combine for a powerful difference.

“It all matters,” says Bobrow. “High-performance CPR by trained rescuers and public access defibrillation and high-quality post-arrest care are all important. But one thing I’ll say is, if you don’t get anyone to do bystander CPR for an out-of-hospital arrest, the odds of survival are very, very low. It’s not impossible, but one of the things most out-of-hospital cardiac arrest survivors have in common is that they had someone at the scene able and willing to do bystander CPR.”

Voices of ECCU

The following comments from top physicians were excerpted from EMS World’s Word on the Street podcasts recorded by Rob Lawrence at December’s Emergency Cardiovascular Care Update Conference, hosted by the Citizen CPR Foundation. Find those at EMSWorld.com/podcast. For more information on ECCU, visit www.citizencpr.org.

Dispatch Life Support

Dispatchers are clearly an emerging and important link in the chain of survival. They have a critical task for identification and coaching of competent CPR. If you look at King County (WA), almost half our bystander CPR is a consequence of our dispatchers identifying the arrest and coaching CPR. So the reason bystander CPR is performed so often in Seattle and King County is in large part because our dispatchers take the bull by the horns and ask those two questions: Is the patient conscious, and are they breathing normally? If no and no, they start compressions. 

When we think about actually touching and saving a life, [dispatchers] are perhaps the most important link in the chain of survival.

—Tom Rea, MD, MPH

First Call, First Contact

If we can catch the arrest at the first call and have first contact with anyone who is trained in medical direction, once you get the logistics of dispatching the call out of the way, you can then use that as an opportunity to facilitate bystander CPR. That goes beyond whether the person knows CPR; the reality is you can give CPR instructions, very basic chest compression instructions, in a very short period of time. You can have hands on the chest very quickly, and we all know that’s the fundamental principle of survival.

The most important thing a medical director for a PSAP can do is institute telephone CPR. You get the information you need to dispatch your folks, and simultaneously you give continuous chest compression CPR instruction, and that can be done in 20 seconds on the phone.

—Michael Kurz, MD, MS

Protocol vs. Performance

If you look at differences in outcomes across communities or EMS services, it’s often not the protocol that’s responsible, but the performance of that protocol—how well are we achieving that high-performance CPR? That’s what’s responsible for whether a community has good or poor survival.

—Tom Rea, MD, MPH

Teaching CPR

When someone collapses it’s quite unsettling, and it can take some initiative to step forward and assess the situation and provide rescue care. So hopefully by teaching receptive learners, the students in middle school and high school, they will understand, appreciate and expect to respond when faced with…cardiac arrest.

—Tom Rea, MD, MPH

‘It Takes Action’

Survival rates from cardiac arrest are not low because of the lack of effective treatment. Early 9-1-1, early CPR and early AED use, consistently provided throughout our communities, would vastly improve survival, but these simple and lifesaving actions are only as good as our communities’ implementation and comprehensive action to provide them. If communities engaged their political, medical, emergency [providers] and citizens, survival rates could go from our current national average of 7% to 20%, 30%, 40% or even 50%, eliminating the epidemic of unnecessary and premature death from this disease.

The lesson we have learned is that as we work together, more lives will be saved. The recently published Institute of Medicine report on cardiac arrest sets a national vision for the future that will save lives—but it takes action.

—Tom Aufderheide, MD (at CPR march)

Different Strokes for Different Folks

Earlier studies have shown improved outcomes with compression-only CPR, and there may be reasons why a more recent one didn't (see page 27). It's not yet universal, however. To the extent there remains opposition, why? The distinguished doc who helped pioneer it has some thoughts.

“I think if you have an organization, like the American Heart Association, that has a history of being the arbitrator of all of this, there can be the idea that, Well, if the Heart Association doesn’t do it, who are these people in Arizona to think differently?” says Gordon Ewy, MD, professor emeritus of cardiology and director emeritus of the Sarver Heart Center at the University of Arizona, whose Resuscitation Research Group pioneered CCO resuscitation. “And there’s this idea that you have to have a randomized controlled trial in man to make any changes. That is going to be almost impossible.”

As well, all patients aren’t equal. They have variations in measures like recognition and response times and differences in features like age and girth (CCO CPR works best in individuals with narrow anterior-posterior chest diameters).

“Why are there arguments here? It’s because there are different populations,” says Ewy. “If you look at a lateral chest x-ray of a thin person, the heart is right under the chest, and you press on the chest, you’re compressing the heart. On the other hand, if you have somebody who has an edematous chest, you take a lateral chest x-ray, their heart is about two inches from there, so you’re not compressing the heart at all when you’re doing that! So I think even for cardiac arrest, the reason there’s so much controversy about ‘Well, is this better or that better?’ is that they’re for different chest configurations.”

References

1. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med, 2015 Jun 11; 372(24): 2,307–15.

2. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA, 2013 Oct 2; 310(13): 1,377–84.

3. American Heart Association. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC, https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf.