Given the importance and potential of bystander CPR in the Chain of Survival, we must build formal dispatch-assisted CPR programs at our 9-1-1 centers. Such programs can be built on any scale, from the smallest 9-1-1 center to county and statewide efforts. Whatever the size, there are three essential pillars: protocol development, dispatcher training and quality assurance (QA) systems that shed light on performance.
The First Pillar: Protocol Development
The American Heart Association scientific advisory statement on dispatch-assisted CPR recommends that dispatchers take an aggressive tack on potential cardiac arrest calls in an effort to initiate bystander CPR within one minute. Callers are often frantic and feel helpless. The first challenge for dispatchers, then, is often to control the call. AHA recommends they assert themselves calmly and ask two critical questions:
1. Is the victim responsive?
2. Is the victim breathing normally?
The caller’s answers aren’t always clear; they can even be contradictory. Specific follow-up questions and techniques can help clarify things, and if the dispatcher thinks a victim is neither responsive nor breathing normally, then he or she should direct the caller to start CPR without delay.
The AHA backs a protocol providing compression-only CPR instructions for adults in arrest of cardiac origin, and conventional CPR instructions when the arrest is secondary to respiratory failure (see http://azdhs.gov/azshare/documents/911/SampleCPRProtocols1.pdf).
Compression-only CPR instructions sidestep fears of mouth-to-mouth contact and get CPR started quicker. The protocol prescribes conventional CPR for children 8 years old or younger, regardless of etiology.
There is concern that the protocol’s aggressive approach may result in high rates of unneeded bystander CPR, or CPR on someone who is not in cardiac arrest. However, research supports this approach. In a study of 247 adult patients not in cardiac arrest, researchers in King County, WA, found only six instances where patients sustained injuries likely or possibly caused by bystander CPR.21 These investigators found no instances of visceral organ damage. The benefits of bystander CPR thus appear to vastly outweigh the risks.
The Second Pillar: Training
Our training should provide clear overviews on the what, why and how of dispatch-assisted CPR, citing the research findings that can foster buy-in from staffers suspicious or uncomfortable with programmatic change. If the study just cited is not referenced in training, for example, dispatchers may be left wondering whether an aggressive approach will result in more harm than good; a subtle push-back can result. Dispatchers may also see QA evaluation as a tool supervisors can use to “punish” their performance, rather than as an instrument to maximize survival. During training, then, it is important to keep the reason for the program clear: It is about saving lives and nothing more.
The Third Pillar: QA Evaluation
The third input, a QA system that allows us to gauge performance, is paramount—no dispatch-assisted CPR program can improve performance without continuous measurement.
Baseline data sets can be drawn by evaluating cardiac arrest calls at a given 9-1-1 center. These calls can be translated into numbers that address key standard-of-care guidelines. An evaluator notes, for example, the time elapsed from call receipt to when the dispatcher recognizes the need for CPR, starts instructions and directs the first compression. We can then calculate averages for these time frames, and compare these with averages derived from calls taken after training and protocol revisions are put in place. By continuously measuring performance, we can identify sticking points and subtleties of process that point the way to future improvements.
Winterstein’s compressions bought Mike Patten time. They created vital blood flow to the brain and other organs and extended VF. Patten is back with his family and doing the lifesaving work he loves. His cardiac arrest has had a dramatic impact on the entire Glendale Fire Department. We are all dedicated to making sure our EMS system works as well as it possibly can for the residents in the communities we serve. EMS providers, it is incumbent on us to create local programs that bring to bear every insight in resuscitation science. Thousands of lives are ours to save. It is our duty to do all we can to save them.