Telephone CPR: Saving Lives Around the World
It came without warning: One moment Joe Andazola was enjoying a round of golf with some friends, the next he fell to the grass unconscious. His heart had ceased to beat rhythmically—it was fibrillating, no longer pumping blood to his vital organs.
His chances of living were slim. Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. In the United States, a mere 8% of victims survive and go home with their families. But Joe, a 73-year-old Phoenix resident, was fortunate. A dispatcher at the Phoenix Fire Department recognized the OHCA early in the 9-1-1 call and provided lifesaving CPR instructions to Joe’s golf buddy of many years, a bystander who’d never done CPR.
“Katie Sheridan (the dispatcher) made all the difference, I’m convinced of that,” says Karen Andazola, Joe’s wife. “She taught CPR over the phone and kept them going, doing the compressions I know saved Joe’s life.”
In Arizona, a campaign to maximize rates of bystander CPR has been improving patient outcomes for the past decade. Bystander CPR can yield a two- to threefold increase in survival, yet on average only about a quarter of victims nationally receive it.1–3 Well-trained emergency medical dispatchers and call-takers, however, can help elevate rates of bystander CPR by providing “just-in-time” CPR instructions to 9-1-1 callers.
The Ramsey Social Justice Foundation recently partnered with the Save Hearts in Arizona Registry and Education (SHARE) Program at the Arizona Department of Health Services to create a standardized measurement tool for telephone CPR (T-CPR) and, with assistance from Laerdal, an interactive T-CPR training video for call-takers and dispatchers worldwide. The Ramsey Foundation has also partnered with the Cardiac Arrest Registry to Enhance Survival (CARES) and Pan-Asian Resuscitation Outcomes Study (PAROS) to spread the latest American Heart Association (AHA) guidelines for the implementation and measurement of T-CPR.
“We are absolutely delighted to work cooperatively with SHARE, CARES and PAROS and their international partners to spread this lifesaving pre-arrival CPR model of care based upon continuous measurement linked to patient outcomes,” says Bob Ramsey, a pioneer in U.S. EMS and ambulance services. “We know from years of experience in EMS, if we can’t measure it, we can’t improve it.”
The one-hour Web-based video teaches the essentials of providing T-CPR, an extremely low-cost intervention that has the potential to save tens of thousands of lives internationally. This massive effort was recently named a Clinton Global Initiative (CGI). The CGI program was established in 2005 by President Bill Clinton to challenge international leaders to devise solutions to the world’s most pressing problems. CGI annual meetings have convened more than 150 heads of state, 20 Nobel Prize laureates and hundreds of leading CEOs, foundation heads and philanthropic leaders to improve the lives of more than 400 million people in more than 180 countries.
The video emphasizes the latest AHA guideline recommendations for T-CPR. It emphasizes three key learning objectives:
- Recognizing cardiac arrests over the phone;
- Overcoming barriers and starting type-appropriate CPR instructions as early in calls as possible;
- Continuously coaching lay rescuers until emergency medical technicians arrive and take over.
At the heart of the course is the AHA “two-question” model for swift recognition: “Is the patient conscious?” and “Is the patient breathing normally?” If the answer to the questions is no, then call-takers and dispatchers should initiate instructions for CPR immediately, avoiding additional questions that can delay the start of CPR.
Since the vast majority of cases call for compression-only CPR (that is, CPR without rescue breathing), the AHA recommends ventilations in addition to compressions only for children less than 9 years old and adults whose arrests have respiratory origins, as in cases of drowning or choking.
The course also emphasizes the importance of dispatchers being assertive in getting CPR instructions started as soon as possible. Dispatchers should never ask callers if they are “willing” or “want” to do CPR—it’s too easy for potential rescuers under immense pressure to say no. Rather, dispatchers should say, “You need to do chest compressions. I will help you—let’s start.”
Finally, dispatchers should have lay rescuers count their compressions out loud. This allows dispatchers to monitor the compression rate, encourage more speed when necessary and switch off when more than one rescuer is present. This continuous coaching can help achieve and sustain the rate of at least 100 compressions a minute.
For 9-1-1 managers and medical directors, the video emphasizes the importance of continuous measurement for maximizing staff proficiency and patient survival. Managers are encouraged to apply methods pioneered in King County, WA. They should listen to a sustainable fraction of their cardiac arrest calls (depending on call center volume and staffing) and track key metrics such as the average times from call start to recognition of cardiac arrest, to start of pre-arrival instructions, and to first compression. The percentage of cases where dispatchers recognize cardiac arrest, start instructions and direct bystander compressions should also be tracked. “Only through continuous measurement and data linkage and analysis can process improvement be gauged over time,” says Ramsey.
The video has now been translated into nine languages as an essential component of T- CPR training in Asia and the Middle East. The T-CPR intervention is underway in the Pan-Asian Resuscitation Outcomes Study, which is a network serving 89 million people in nine countries. PAROS benchmarks outcomes against established registries to generate best-practice protocols for emergency medical service systems and elevate community awareness of prehospital emergency care. It collects data from dispatch centers, ambulance providers, emergency departments and hospital collaborators to build a registry that facilitates comparative research to improve patient outcomes. To date there are more than 60,000 patient cases in the PAROS database.
For more on the T-CPR course, visit http://azdhs.gov/azshare/911/Info4Dispatchers.htm.
- T-CPR course, http://azdhs.gov/azshare/911/Info4Dispatchers.htm
- Cardiac Arrest Registry to Enhance Survival (CARES), http://www.cdc.gov/dhdsp/cares.htm
- Clinton Global Health Initiative (CGI), http://get.cgilink.org/v/c/803090
- Pan-Asian Resuscitation Outcomes Study (PAROS), http://www.scri.edu.sg/index.php/2012-12-10-10-15-18/networks-paros
- Ramsey Social Justice Foundation, http://ramseyjusticefoundation.org
- Save Hearts in Arizona Registry and Education (SHARE) Program, http://azshare.gov
1. Cummins RO. Emergency medical services and sudden cardiac arrest: the “chain of survival” concept. Annu Rev Public Health, 1993; 14: 313–33.
2. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O’Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y; for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 2008 Jan 29; 117(4): e25–146.
3. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2005; 112 (suppl): IV-1–IV-203.
Micah Panczyk is 9-1-1 CPR program manager at the Arizona Department of Health Services. A former newspaper reporter and editor, he holds two master’s degrees and lives in Phoenix, AZ.
Bryan F. McNally, MD, MPH, is an associate professor of emergency medicine at Emory University School of Medicine in Atlanta. His areas of expertise are emergency medicine and prehospital and disaster medicine. He is executive director of the CARES (Cardiac Arrest Registry to Enhance Survival) Program, a national out-of- hospital sudden cardiac arrest surveillance registry, and serves as a consultant to the Pan-Asian Resuscitation Outcomes Study (PAROS). In addition to his academic and administrative duties, Dr. McNally is a practicing emergency medicine physician at Emory University Midtown Hospital, a tertiary-care academic medical center, and Grady Memorial Hospital, a public hospital with a Level 1 trauma center and more than 100,000 emergency department visits per year.
Bentley J. Bobrow, MD, is professor of emergency medicine at the University of Arizona College of Medicine—Phoenix Campus and practices at Maricopa Medical Center in Phoenix, AZ. He has partnered with public health officials, EMS agencies, municipal fire departments, hospitals, university researchers and the public to develop a statewide reporting and educational network for responding to out-of-hospital cardiac arrest. This system of care has resulted in a significant increase in the rates of bystander CPR and a tripling of survival from sudden cardiac arrest in Arizona.