Dispatcher-Directed Cardiopulmonary Resuscitation (CPR)—CPR instructions provided over the phone by a certified emergency medical dispatcher (EMD)--is one of the most important, time critical, tasks the EMD performs. Immediate initiation of bystander CPR is paramount in the survival of out of hospital cardiac arrest (OHCA) patients. When handling such a case, EMD actions must be precise and efficient. This only happens when EMDs follow the scripted Medical Priority Dispatch System (MPDS) protocols in the ProQA^™ software consistently and indiscriminately.

Over the months of March, April, and May, I performed a focused performance analysis on cardiac arrest cases taken by our EMD staff at East Baton Rouge Emergency Medical Services (EBREMS), consisting of International Academy of Emergency Dispatch (IAED) certified EMDs, who are also National Registry Emergency Medical Technicians (NREMTs) at differing levels of certification. Cardiac and respiratory arrest calls were collected through the use of AQUA^™ case review software. Also utilized were the 911 audio recordings, and real time screen capture of the EMD’s actions throughout the call taking process.

The data collected consisted of five data points: time to recognition of cardiac/respiratory arrest, use of the Fast Track feature in ProQA, barriers incurred while instructing callers on CPR, time to first compression (hands-on-chest), and non-arrest cases that the EMD initially assessed as an arrest and assigned an arrest code in the Case Entry sequence (misidentified arrests). All times measured  began at the time of phone pick-up and were recorded as elapsed time in seconds. The data was collected by month, averaged by month, and then averaged over the complete three-month period. A total of 170 calls were utilized for this data collection.

Arrest recognition time was calculated as the elapsed time from phone pick up to the point the EMD assigned an arrest Determinant Code in ProQA. The average time for the three-month period was 45 seconds. The American Heart Association (AHA) benchmark time for dispatcher arrest recognition is <90 seconds, and the goal for high performance dispatch systems is <60 seconds.¹  

Therefore, this analysis confirms that, using the MPDS, EMDs are doing an exceptionally good job at early recognition of OHCA using the caller information provided during MPDS Case Entry questioning—confirming what EMDs are taught in their IAED certification training.   

The use of the ProQA Fast Track feature—used to identify the cases of ‘OBVIOUS not breathing (non-trauma),’ based on the caller’s initial patient description-- was averaged by the total number of calls reviewed divided by the total uses of the tool. In the first month this tool was utilized only 18.5% of the time. It was recognized that this seemed a low average. After training and re-enforcement of tool use, we saw an increase in months two and three to 35%, and 26.6%, respectively. This gave us a three-month average of 26.7% use. Fast Track is the EMDs best friend in cardiac arrest situations, where it is applicable. Utilizing Fast Track reduces redundancy and speeds up the process to deliver potentially lifesaving Dispatcher-Directed CPR.

 48% of all arrest calls taken presented some type of barrier to resuscitation. I included the following as barriers: difficulty validating a patient address/location, problems positioning or accessing the patient for CPR, language or communication problems, hysteria, uncooperative callers, refusal, or reluctance to perform CPR, and  any other time-consuming delays in performing CPR. One of the most important steps to overcoming barriers is knowing that we will incur them. A previous study confirms my findings here—that barriers on CPR cases are common at 911, and often the norm.² The MPDS provides us with many ways to overcome these. First, we have the protocol itself. Adherence to the order, and scripting of the questions and instructions is important. The protocols are not written by happenstance. Panels of experts in their respective fields have poured countless hours into the development of the protocols, therefore we can use them in complete confidence. Second, we should recognize that difficulty in properly positioning the patient—on the floor or ground in a supine position—is perhaps the most common  barrier for the EMD. So, we should be prepared to use the specific dispatch life support (DLS) links that allow us to instruct callers on moving these patients into position (e.g., rolling patients over, removing them from a bed, chair, etc.).

Third, when positional barriers cannot be overcome, we still do not give up on resuscitative efforts. CPR, if needed, can be performed on a bed, and even in the prone position. Fourth, our customer service techniques are useful when callers require encouragement, repetitive persistence, and assurance. We must never allow barriers to be a segway into “giving up” on resuscitative efforts.

I collected hands-on-chest data by calculating the time lapse from phone pick-up to the first compression actually performed by the caller or compressor. Consistently, these times remained in the 180-200 second range. The three-month average time was 195 seconds (3:25). While this is higher than the AHA benchmark time of 150 seconds,¹ it is a more complete picture of actual OHCA events, since AHA allows for numerous exclusions of the data (“denominator exclusions”) based on different barriers. I have left all these cases in our data for completeness.  

 CPR is an absolute time-sensitive task, with severe and permanent brain damage likely after a delay of just a few minutes of blood flow. As EMDs we must begin compressions as soon as possible. In these instances, there is no time for indecision, inattentiveness, or inefficiency.  We must make the most of every moment we spend with our callers. Protocol adherence and, when possible, Fast Track use, are paramount.  

While collecting compression data from the case audios, I found that EMDs sometimes unnecessarily tried to fill time during the performance of CPR by speaking to the compressor with ad-libbed remarks not in the protocol script. This, more often than not, caused the compressor to stop compressions, to listen to the question (or statement) and respond to it. Insignificant questions such as “How long have they been down?” “Do they have any medical problems?” and “When was the last time you saw them?” are all inconsequential. Once CPR is started, it does not get interrupted unless the patient is revived and awake, or a trained field responder takes over. 

Uninterrupted CPR helps maintain arterial pressure and end-organ blood flow (perfusion). Our focus should be “Compress more, talk less!” When we distract our callers with superfluous, freelanced statements, it’s only natural they will stop what they are doing to listen to us. Therefore, statements and questions that do not change response level or provide for scene or responder safety is counterproductive.

Finally, our agency was concerned about callers who initially described an arrest, although the patient was later determined not actually in arrest {i.e., misidentified arrests). I computed the percentage of suspected arrest patients who were initially given an arrest description by the caller, then later determined to be not arrested through additional caller information as the call progressed--for example, overdose or seizure patients who “woke up,” and or patients that were “just sleeping.”  The average error in caller description was only 5.22% as determined by the EMD. For this report, patient status was not compared directly to paramedic findings after arriving on scene, however our agency has done such comparisons in the past and found high correlation between an arrest found at scene by paramedics and the dispatch determination of arrest.

To put this in perspective think about a baseball player that only strikes out 5.22% of at bats. This player would probably make a large salary and have a long contract.  Suffice it to say when callers give this information, believe them!

To summarize my findings: EMDs must pay close attention to caller information while following their dispatch protocols. EMDs should believe their callers—they are usually right.  When appropriate, EMDs should utilize the arrest Fast Track feature in the ProQA software. Know that you will encounter barriers and be prepared for them. Hands-on-chest time is vitally important, but so is accuracy and safety—the MPDS will manage all these factors in the shortest time possible.    

 

References:

1. Kurz MC, Bobrow BJ, Buckingham J, Cabanas JG, Eisenberg, M, Fromm P, Panczyk MJ, Rea T, Seaman K, Vaillancourt C, MD, On behalf of the American Heart Association Advocacy Coordinating Committee. Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association. Circulation. Volume 141, Issue 12, 24 March 2020; Pages e686-e70 https://doi.org/10.1161/CIR.0000000000000744

2. Scott G, Broadbent M, Gardett I, Sangaraju S, Clawson JJ, Olola C. Barriers Significantly Influence Time to Bystander Compressions in Out-of-Hospital Cardiac Arrest. Ann Emerg Dispatch & Response. 2019; 7(1):17-23.