Hot Topics in Telephone CPR

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1 Hot Topics in Telephone CPR Bentley J. Bobrow, MD, FACEP Professor, Emergency Medicine Maricopa Medical Center University of Arizona College of Medicine-Phoenix

2 Disclosure PI Arizona HeartRescue Project PI NIH R01 Traumatic Brain Injury EPIC is funded by the NIH (NINDS) 1R01NS (Adults) 3R01NS S1 (EPIC4Kids)

3 HeartRescue Partners

4 Important Questions about Telephone-CPR: 1. Do pre-arrival CPR instructions significantly improve survival from OHCA? 2. Do specific questions improve the speed/accuracy/quality of T-CPR? 3. Does time to 1 st compression improve survival? 4. What are the central barriers to widespread adoption? 5. How should we implement and measure this?

5 Conceptual Framework CPR

6 Factors Contributing to Survival Two Critical Elements to Survival: 1) Time from collapse to initiation of CPR 2) Time from collapse to application of AED

7 Typical Urban Response Timeline USA 0:00:30 0:02:17 0:03:44 0:09:16 0:9:16-0:11:16 0:11:16-0:13:16 PSAP Handling Turnout Travel To patient First shock 0:00:30 0:01:47 0:01:27 0:05:32 0:01:00-0:02:00 0:01:00-0:02:00

Importance of Bystander CPR The OR for Bystander CPR was 2.44 (95% CI, 1.69-3.

8 Importance of Bystander CPR The OR for Bystander CPR was 2.44 (95% CI, ) (Sasson et. al. Circulation: Cardiovascular Quality and Outcomes Nov )

9 Bystander CPR Rates 32% New York (Gallagher, 1995) 21% Detroit (Swor, 1995) 15% Ontario, Canada (Stiell, 2004) 19% Europe, (Wenzel, 2004) 28% SOS KANTO (Nagao, 2007) 27% Osaka, Japan (Iwami, 2007) 25% Singapore (Ong, 2008) 25% CARES Registry (McNally, 2009) 25% Arizona SHARE (Vadeboncoeur, 2007)

10 Training/Education THE SYSTEM of CARE Hospital EMS Dispatch Data QI/reports Bystander

11 The Rationale 1. Emergency Dispatch Almost Universal 2. Existing 24/7 Infrastructure 3. Very Little Extra Cost 4. Public Understands to Call 5. Early Point of Intervention

12 The Math Train 10,000 bystanders ~ 1 cardiac arrest Train 1 dispatcher = many cardiac arrest

13 Multiple Barriers to Performing Bystander CPR Sasson - AHA Scientific Advisory Statement. Circulation 2013

14 Bobrow et al. Current Opinions Critical Care. 2012

15 COMBINATION CP R EXP OSURE AND JUST-IN-TIME TRAINING Cardiac arrest can be hard to identify Rescuers lack confidence to act CPR can be technically difficult Fear of causing harm Reluctance to M-T-M

16 CPR 1. Do pre-arrival CPR instructions improve survival from OHCA?

19 Benefit of T-CPR compared to Native CPR Rea et al. Circulation 2003

20 Three-month survival was 5% when a cardiac arrest was not recognized versus 14 % when it was recognized.

21 Survival to Discharge T-CPR Instructions - Survival (p=0.0453) /223 (31.7%) 53/123 (43.1%) 0 No TCPR TCPR Kuisma Resuscitation

22 CPR 2. Do specific terms improve the speed/accuracy/quality of T-CPR?

23 Agonal (Gasping) Breathing Abnormal breathing in unresponsive patients A brainstem response to lack of oxygen Can help recognition of OHCA Occurs in ~ half of cardiac arrests Associated with improved survival

24 80% Gasping Following Out-of-Hospital Witnessed Cardiac Arrest 60% 40% 20% 10% 0% 55% Dispatch 39% Dispatch Witness 33% After EMS arrival 20% EMS < 7 min 14% EMS 7-9 min 7% EMS >9 min Clark et al. Ann Emerg Med 1992 Bobrow et al. Circulation 2008

29 2-Question Approach AHA Science Advisory 2012

31 CPR 3. Does time to first compression matter?

32 survival Time is Critical Survival decreases by 10% for every minute treatment is delayed time to cpr and shock

35 CPR 4. What are the central barriers to widespread adoption?

36 Most Common Impediments 1. Most say they already give pre-arrival instructions 2. Most are not familiar with the Guidelines 3. Most don t understand the issues (gasping, seizures, etc.) 4. Almost none measure/benchmark 5. Most dispatchers/call-takers are not confident

37 5686 identified PSAPs in the US 3555 (62%) received survey (valid addresses) 1917 (54%) responded 1038 (54%) provide PAI for medical emergencies 879 (46%) provide no PAI for medical emergencies 1005 Provide PAIs for OHCAs 66 (7%) compression only CPR instructions 698 (69%) conventional CPR instructions 166 (17%) report some other instructions (chest compressions with rescue breathing) 75 (7%) did not specify type of PAI provided 606 (69%) able to transfer caller 273 (31%) unable to transfer caller to another source for PAI Roosa et al. NAEMSP 2014

38 Type of Pre-Arrival Instructions N=1005 7% 7% Compression-Only CPR 17% Conventional CPR (CCs with RB) Other - incorporating ventilations and compressions 69% Did not specify type of PAI provided Roosa et al. NAEMSP 2014

40 CPR 5. How should we implement/measure this?

42 Measurement: The Key to Improving % cases recognition % cases CPR instructions started % cases T-CPR begins Time to recognition Time to start of instructions Time to start of compressions

43 Performance Standards % cardiac arrests recognized: 95% Time to recognize cardiac arrest: 60 seconds % cardiac arrests that receive ccs: 75% Time to first chest compression: 120 seconds Dispatch time of first-in unit: 30 seconds

44 Time to recognize cardiac arrest: King County, Washington Agency Total Calls *N/A 0-20 Seconds Seconds Seconds 60 Seconds or Less Seconds Seconds 100+ Seconds Enumclaw Norcom POS VCC % 6% 33% 13% 91% 6% 2% 1%

45 Time (in Seconds) Arizona Data Telephone-Assisted CPR Times: Before & After Time to Recognition Time to Start Instructions Time to First Compression Pre Post The above shows reductions in time from call-receipt to (1) dispatch recognition of the need for CPR, (2) start of dispatch pre-arrival CPR instructions and (3) first dispatch-directed bystander chest compression after implementing guideline-based protocols and training instruments for Telephone- Assisted CPR at three centers in Arizona. All results are statistically significant.

AZSHARE Dispatch CPR Reporting Template Total

Pediatric Arrests n= Compressions Only n=

Only n= DACPR Instructions Not Delivered n =

Non-Cardiac CPR in Progress n= Failure to

n = Obvious Death n = Difficult Access n =

Instructions Given n = AVG Time of Breathing

Time to Dispatch Recognition t = AVG Time to

Compression t = AVG Time to First Ventilation

46 AZSHARE Dispatch CPR Reporting Template Total Calls Reviewed n = DACPR Not Indicated n= Pediatric Arrests n= Compressions Only n= Compressions and Ventilation n= Ventilation Only n= DACPR Instructions Not Delivered n = DACPR Indicated n = DACPR Instructions Delivered n = Adult Arrests n= Cardiac Etiology n= Compressions Only n= Compressions and Ventilation n= Ventilation Only n= Non-Cardiac Etiology n= Compressions Only n= Compressions and Ventilation n= Ventilation Only n= CPR in Progress n= Failure to Recognize n = Caller Refused n = Caller Unable n = Obvious Death n = Difficult Access n = Bystander CPR Performed n = Appropriate CPR Instructions Given n = AVG Time of Breathing Assessment t = AVG QI Recognition Time t = AVG Time to Dispatch Recognition t = AVG Time to Start of Instruction t = AVG Time to First Compression t = AVG Time to First Ventilation t = AED use n = Survival to Hospital Discharge n= Death n=

Exporting Dispatch data 1. Perform a Search on the CARES Search page for your date of interest. 2. Sort results by Date of Arrest by clicking on the column header. 3.

48 Exporting Dispatch data 1. Perform a Search on the CARES Search page for your date of interest. 2. Sort results by Date of Arrest by clicking on the column header. 3. In the Send results to drop-down menu, select Excel export of dispatch data and click Go. 4. The search results can be opened or saved in an Excel document for further analysis.

49 Reports The following reports would be available under the Reports tab within the CARES account: 1. % of cases correctly identified by dispatch center 2. Time from call receipt to Bystander CPR instruction being provided 3. Time from call receipt to first bystander compression

50 Telephone-CPR Bundle Web-based Telephone-CPR Training Continuous data collection/benchmarking Provider and system level feedback Focused revisions based upon data

52 We are unlikely to maximize survival rates without fully implementing this intervention Summary Early dispatch recognition of cardiac arrest can significantly improve survival Telephone-CPR can double the rate of BCPR Widespread implementation/measurement are feasible and efficient

53 Acknowledgements King County EMS Drs. Eisenberg and Rea Laerdal Helge Myklebust Ramsey Foundation PAROS Drs. Ong, Shin, Tanaka, and Ng CARES Dr. McNally CPR

54 List of Resources Training video: Training webinar for data entry: Data Dictionary on the CARES website ( > Education/Resources tab> Dispatcher Assisted CPR Training Training video and tools:

EMD CPR. The First First Responder. R. Darrell Nelson, MD, FACEP. Emergency Medicine Wake Forest University Baptist Health

EMD CPR. The First First Responder. R. Darrell Nelson, MD, FACEP. Emergency Medicine Wake Forest University Baptist Health EMD CPR The First First Responder R. Darrell Nelson, MD, FACEP Emergency Medicine Wake Forest University Baptist Health The First, First Responder Objectives 1. Why does EMD matter? 2. Review Role of EMD