Sutter, John

Background: Bystander cardiopulmonary resuscitation (BCPR) significantly improves survival from out-of-hospital cardiac arrest (OHCA). Telecommunicator CPR (TCPR) has been shown to increase BCPR rates, yet TCPR performance varies widely. We assess whether a bundled TCPR protocol, training, and continuous quality improvement (CQI) intervention improves TCPR performance. Methods: The intervention was implemented at a regional 9-1-1 dispatch center and had three main components: (1) the installation of the AHA-recommended 2-question TCPR protocol, (2) training to enhance telecommunicator OHCA recognition and (3) CQI with system and case-level feedback. Training included a two-hour lecture, 30 minutes of video training, and one hour of simulation training. Audio recordings of suspected OHCAs from pre (P1, 10/5/10 - 11/6/11) and post-intervention (P2, 11/7/11 - 11/4/13) periods were collected by searching center archives for calls originally processed as cardiac arrests. Recordings were analyzed according to six key TCPR metrics. Times to telecommunicator recognition of cardiac arrest, start of TCPR instructions, and initiation of chest compressions were measured using a standardized timestamp format. Results: Rates of OHCA recognition (80% to 95%, p<0.0001), TCPR instructions started (32% to 72%, p<0.0001), and bystander chest compressions initiated (18% to 70%, p<0.001) all increased significantly. Reductions in the time from call receipt to the start of TCPR instructions (176s to 133s, p<0.0001) and to the start of compressions (265s to 162s, p<0.0001) were also observed. Conclusion: This bundled protocol, training and CQI intervention was associated with a significant increase in TCPR rates and a reduction in the time to first chest compression.

Background: Bystander CPR (BCPR) and telephone CPR (TCPR) are associated with improved OHCA outcomes. It has been shown that BCPR increases the proportion of patients with an initial shockable cardiac rhythm (VF/VT) when encountered by EMS. It is unknown whether TCPR does the same. Objective: To assess whether TCPR is independently associated with an increase in initial shockable cardiac rhythms during OHCA. Methods: Data from 9-1-1 audio recordings, first care EMS reports and hospital records were linked for OHCAs of presumed cardiac origin (1/2011-12/2014). Three cohorts were analyzed: TCPR, BCPR or no CPR. Using no CPR as the reference group, we assessed whether TCPR and BCPR were independently associated with initial shockable rhythms in a logistic regression model controlling for gender, event location, witness status and EMS response interval. Results: After exclusions, 2715 adult OHCA events with linked outcome data were analyzed (median age: 63; male: 66.8%; 33.3% witnessed arrest). Median response interval was 5 min. The BCPR rate (lay rescuer CPR without telephone instructions) was 24.8% and survival in this group was 15.4%. The TCPR rate (lay rescuer CPR with telephone instructions) was 40.2% and survival in this group was 11.7%. For the no-CPR group, 20.5% had an initial shockable rhythm. For the BCPR group, 34.6 % had an initial shockable rhythm. For the TCPR group, 23.2% had an initial shockable rhythm. Provision of BCPR and of TCPR were each independently associated with shockable rhythms [aOR (BCPR) = 1.7, 95% CI: 1.33-2.17, p=0.0001; aOR (TCPR) = 1.3, 95% CI: 1.04-1.63, p=0.0001]. Conclusion: The provision of both BCPR and TCPR were independently associated with an increased rate of initial shockable cardiac rhythms and an increase in survival to hospital discharge compared to no CPR.

Background: Bystander CPR (BCPR) increases survival from OHCA yet is provided in a minority of cases. The AHA has promulgated guidelines on the provision of pre-arrival Telephone CPR (TCPR) instructions and measurement to increase the proportion of BCPR; however, the impact of those guidelines on survival is unknown. Objective: To describe the impact of a comprehensive bundle of 9-1-1 TCPR protocol, training, data collection, and feedback on BCPR and survival from OHCA across the state of Arizona. Methods: 9-1-1 audio recordings of confirmed OHCAs and suspected OHCAs (10/2010-6/2013) in 7 large 9-1-1 centers were reviewed using a standardized time-stamp methodology linked with EMS and hospital process and outcome data. There were 2343 pre-implementation cases (P1) and 2291 cases post-implementation of a bundle of care (P2) that included staff training and guideline-based protocol changes, data collection and feedback to providers. Univariate and multivariable analyses were used to assess outcomes between P1 and P2. Results: There were 2532 OHCAs [1232 P1, 1300 P2; 64% male, median age 62 (IQR: 47-74)]. 83% of cases were identified in P1 compared with 89% in P2 (p<0.001). The rate of telephone-assisted BCPR went from 44% in P1 to 62% in P2 (p<0.001). Time to beginning TCPR instructions decreased from a median of 144 sec (P1) to 126 in P2 (p<0.001). Time to first chest compression also decreased (P1: 178; P2: 155; p<0.001). Outcome data are currently available for 64% of confirmed OHCAs (1630 patient outcomes with 1619 neuro outcomes). Survival was significantly higher in P2 (11.2%) compared to P1 (7.9%; p=0.023), as was good neuro outcome (CPC-1 or 2: 7.7% P2 vs. 4.8% P1 p=0.018). After adjusting for witnessed arrest, shockable rhythms, age, and sex, both survival and good neuro outcome were still significantly higher in P2 vs. P1 [adjusted odds ratios: survival = 1.5 (95% 1.1-2.1); good neuro outcome = 1.7 (95% 1.1-2.6)]. Conclusion: The implementation of a comprehensive statewide TCPR bundle was associated with significant improvements in the rates of telephone-assisted BCPR, survival and good neurologic outcome after OHCA.

Background: Higher chest compression release velocity (CCRV) is associated with better outcomes after OHCA. Patient age and gender have been associated with variations in chest wall compliance and compressibility which may impact outcomes. Hypothesis: To evaluate the association between CCRV and OHCA patient age, weight, and gender. Methods: Observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Patient age and weight were categorized into quartiles for the analysis. CCRV was summarized at each level of the categorical variable by median and inter-quartile range (IQR), and was then compared between different levels by the Kruskal-Wallis test. Results: During the study period, 2,661 OHCA cases were treated. After exclusion criteria, 1,140 cases remained for analysis. Median duration of compressions was 8.70 minutes. Mean CCRV was negatively correlated with age and positively correlated with weight (Table). Male patients exhibited a greater mean CCRV compared to female patients [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 (285.3-385.5), p=0.0133]. Conclusion: Patient characteristics including younger age, male gender, and increased weight were associated with a higher CCRV during OHCA resuscitation.