Emergency Care: Dispatcher instruction in CPR

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Emergency Care: Dispatcher instruction in CPR

Citation

Olasveengen TM, Mancini ME, Vaillancourt C, Brooks SC, Castren M, Chung  SP, Couper K, Dainty KN, Escalante R, Gazmuri RJ, Hatanaka T, Kudenchuk PJ, Lim SH, Nikolaou N,

Nishiyama C, Perkins GD, Ristagno G, Smyth MA, Morley P

Collaborators:

Considine J,  Løfgren B, Nolan J, Stanton D, Travers A

Dispatcher instruction in CPR for Adults Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2018 October 8.  Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence process for the production of Consensus of Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support (Nikolaou, 2018, – PROSPERO - CRD42018091427) conducted by an expert systematic review team with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Adult Task Force and the Pediatric Task Force groups respectively.

This evidence review sought to evaluate the efficacy of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions during out-of-hospital cardiac arrest. We identified two main types of comparisons in the literature.  The first type included before-and-after studies and cohort studies comparing outcomes of patients who were offered dispatch-assisted CPR with those who were not offered dispatch-assisted CPR.  The second type included  outcomes for patients who actually received dispatch-assisted CPR with those who  did not receive dispatch-assisted CPR.

Separate meta-analyses were performed for studies employing each type of analysis  and included both unadjusted and adjusted outcomes. The number of confounders that were adjusted for in the multivariable analyses ranged from 4 to 11. The most frequently used ones were: gender 11/ 14 (79% of studies), witnessed arrest 10/14 (71% of studies), location of arrest (public vs. home, 9/14- 64% of studies), call to response time 9/14 (64% of studies), shockable initial rhythm 6/14 (43% of studies), and etiology of cardiac arrest 5/14 (36% of studies).

Studies reporting children were included in the systematic review; however, the current consensus on science with treatment recommendations is limited to adults with the corresponding children counterpart published by the Pediatrics Task Force.

Systematic Review

Link to come.

Emergency Care: Dispatcher instruction in CPR PICOST

The PICOST (Population, Intervention, Control, Outcomes, Study design and Timeframe)

Population:  Adults and children with presumed cardiac arrest in out-of-hospital settings.

Intervention:  Patients/cases or EMS systems where dispatch assisted CPR is offered.

Comparators:  Studies with comparators where either systems or specific cardiac arrest cases are not offered dispatch-assisted CPR are included.

Outcomes: Critical: Survival with good neurological function (at hospital discharge, 1 month or 6 months), survival  (hospital discharge, 1 month or 1 year survival), short term survival (return of spontaneous circulation – ROSC, hospital admission), provision of bystander CPR. Important: initial shockable rhythm, time to CPR.

Study DesignsRandomised controlled trials (RCTs) and non-randomised studies (non-randomised controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.

Timeframe:  All years and all languages are included with the last search being performed July 1st 2018. Ongoing or unpublished studies were identified through a search of www.clinicaltrials.gov online registry.

PROSPERO - CRD42018091427

Consensus on Science

Studies comparing outcomes from patients when dispatch-assisted CPR instruction was offered with outcomes from patients when dispatch-assisted CPR instruction was not offered

Sixteen studies were included in this meta-analysis (Culley 1991 362, Song 2014 34, Stipulante 2014 177, Vaillancourt 2007 877, Besnier 2015 590, Harjanto 2016 85) or cohorts (Bang 1999 175, Kuisma 2005 89, Akahane 2012 1410, JCSRSSG 2013 2742, Goto 2014 e000499, Hilltunen 2015 266, Fukushima 2015 e005058, Moriwaki 2016 220, Ro 2016 20, Takahashi 2017 384) Only 4 of these papers provided adjusted analysis for any of the critical and important outcomes. Although unadjusted analysis might be confounded by concurrent temporal changes or systematic differences between cohorts, both unadjusted and adjusted analysis were deemed essential.             

Survival with good neurological function (at hospital discharge, 1 or 6 months)

For the critical outcome of survival with good neurological function at hospital discharge, 1 or 6 months, we identified very low certainty evidence from 6 studies evaluating the effect of dispatch-assisted CPR (Discharge: before-after studies: Song 2014 34, Besnier 2015 590; 1 month: before-after study: Harjanto 2016 85, cohort studies: Takahashi 2017 384, Goto 2014 e000499; 90 days: Hilltunen 2015 266).

The meta-analysis of unadjusted data on survival with good neurological function at hospital discharge (before-after studies: Song 2014 34, Besnier 2015 590) included 5533 out of hospital cardiac arrest patients and showed benefit when dispatch-assisted CPR was offered [Odds Ratio (OR) 1.70 (95% Confidence Interval (CI) 1.21, 2.37); Relative Risk (RR) 1.67 (95% CI 1.21, 2.31); p=0.002]; 14/1000 more patients benefited with the intervention [95% CI 4 more patients /1000 to 27 more patients / 1000] when compared with dispatch-assisted CPR not being offered. Adjusted analysis from 1 of these studies (before-after study: Song 2014 34) showed higher survival with good neurological function at hospital discharge in the EMS system after implementation of dispatch-assisted CPR [ORadj 1.67 (1.13, 2.47); RR: NA; Adjusted RR - ARR: NA ; p=0.01]. The certainty of evidence was very low (downgraded for serious risk of bias).

The meta-analysis of unadjusted data on survival with good neurological function at 1 month (before-after study: Harjanto 2016 85, cohort studies: Takahashi, 2017 Goto 2014 e000499) included 44698 out of hospital cardiac arrest patients and showed benefit when dispatch-assisted CPR was offered [OR: 1.10 95% CI: (1.03, 1.17); RR 1.09 (95% CI: 1.03-1.15;p=0.004]; 9 more patients/1000 benefited with the intervention [95% CI, 3 more patients/1000 to 15 more patients/1000] when compared with dispatch-assisted CPR not being offered. Adjusted analysis from 2 of these studies (before-after study: Harjanto 2016 85, cohort study: Goto 2014 e000499) showed higher survival with good neurological function at 1 month when dispatch-assisted CPR was offered [ORadj of 1.47 (1.03-2.09); RR: NA; ARR: NA p=0.03] when compared with dispatch-assisted CPR not being offered. The certainty of evidence was very low downgraded for serious risk of bias.

One study reported unadjusted survival with good neurological function at 6 months (cohort study: Hiltunen 2015). This study included 164 out of hospital cardiac arrest patients and showed similar survival with good neurological function at 6 months with and without dispatch-assisted CPR being offered [OR 1.37 (0.64, 2.25); RR: 1.27 (0.72, 2.27); p=0.14, 57/1000 more patients benefited with the intervention [95% CI 7 fewer patients/ 1000 to 204 more patients /1000 ]. The certainty of evidence was very low downgraded for serious risk of bias, serious indirectness and serious imprecision. 

Survival (hospital discharge, 1 month or 1 year survival)

For the critical outcome of survival to hospital discharge, 1 month or 1 year, we identified very low certainty evidence from 9 studies evaluating the effect of dispatch-assisted CPR (hospital discharge: before-after study: Culley 1991 362, Song 2014 34, Stipulante 2014 177, Vaillancourt 2007 877, cohort studies: Bang 1999 175, Hilltunen 2015 266, Kuisma 2005 89; 1 month: before-after study: Harjanto 2016 85, cohort study: Goto 2014 e000499; 1 year: cohort study: Hilltunen 2015 266).

The meta-analysis of unadjusted data on survival to hospital discharge (before-after studies: Culley 1991 362, Song 2014 34, Stipulante 2014 177, Vaillancourt 2007 877, cohort studies: Bang 1999 175,  Hilltunen 2015 266, Kuisma 2005 89) included 14139 out of hospital cardiac arrest patients and showed similar survival to hospital discharge with and without dispatch-assisted CPR being offered [OR  1.23 (0.99-1.53); RR 1.18 (0.99, 1.41) ; p=0.07; 33/1000 more patients benefited with the intervention [95% CI 2 fewer patients /1000 to 73 more patients per 1000]. The certainty of evidence was very low, downgraded for very serious risk of bias and serious inconsistency and imprecision. Adjusted analysis from 1 of these studies (before-after study: Song 2014 34) showed higher survival to hospital discharge after implementation of dispatch-assisted CPR [ORadj of 1.33 (1.07-1.66); RR: NA; ARR: NA ; p=0.01]. The certainty of evidence was very low, downgraded for serious risk of bias.

The meta-analysis of unadjusted data on survival to 1 month (cohort studies: Harjanto 2014, Goto 2014 e000499) included 6799 out of hospital cardiac arrest patients and showed similar outcomes with and without dispatch-assisted CPR being offered [OR 1.20 (0.99-1.45); RR 1.18 (0.99, 1.40); p=0.06); 11/1000 more patients benefited with the intervention [95% CI 1 fewer patients /1000 to 25 more patients per 1000]. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision. Meta-analysis of adjusted data on survival to 1 month (before-after study: Harjanto 2014, cohort study: Goto 2014 e000499) showed higher survival to 1 month when dispatch-assisted CPR was offered [ORadj of 1.40 (1.07-1.85); RR: NA; ARR: NA; p=0.01] when compared with dispatch-assisted CPR not being offered. The certainty of evidence was very low, downgraded for serious risk of bias.

One study reported unadjusted survival to 1 year (cohort study: Hiltunen 2015). This study included 164 out of hospital cardiac arrest patients and showed similar outcomes with and without dispatch-assisted CPR [OR 1.03 (0.51, 2.07); RR: 1.02 (0.90, 1.16); p=0.94, 7/1000 more patients benefited with the intervention [95% CI 125 fewer patients/ 1000 to 173 more patients /1000 ]. The certainty of evidence was very low downgraded for very serious risk of bias and imprecision.

Short term survival (Return of Spontaneous Circulation – ROSC, hospital admission)

For the critical outcome of ROSC and survival to hospital admission, we identified very low certainty evidence from 8 studies evaluating the effect of dispatch (ROSC: before-after studies: Harjanto 2016 85, Song 2014 34, Vaillancourt 2007 877, cohort studies: Takahashi 2017 384, Hilltunen 2015 266; hospital admission: before-after studies:  Harjanto 2016 85, Song 2014 34, Vaillancourt 2007 877, cohort studies: Moriwaki 2016 220, Fukushima 2015 e005058, Besnier 2015 590).

The meta-analysis of unadjusted data for ROSC (before-after studies: Harjanto 2016 85, Song 2014 34, Vaillancourt 2007 877, cohort studies: Takahashi 2017 384, Hilltunen 2015 266) included 49229 out of hospital cardiac arrest patients and showed benefit when dispatch-assisted CPR was offered [OR 1.17 (1.08-1.27); RR 1.11 (1.07, 1.15); p<0.0001; 27/1000 more patients benefited with the intervention [95% CI 13 patients /1000 to 42 more patients per 1000]  when compared with dispatch-assisted CPR not being offered. The certainty of evidence was very low, downgraded for serious risk of bias. Adjusted analysis from one of these studies (Harjento 2016) showed similar benefited with and without dispatch-assisted CPR being offered [ORadj of 1.14 (0.88-1.48); RR: NA; ARR: NA; p=0.25]. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision.

The meta-analysis of unadjusted data for survival to hospital admission (before-after studies: Harjanto 2016 85, Song 2014 34, Vaillancourt 2007 877, cohort studies: Moriwaki 2016 220, Fukushima 2015 e005058, Besnier 2015 590) included 9548 out of hospital cardiac arrest patients and showed similar survival to hospital admission with and without dispatch-assisted CPR being offered [OR 1.08 (0.95, 1.23); RR 1.05 (0.95, 1.17); p=0.35; 12/1000 more patients benefited with the intervention [95% CI 8 fewer patients /1000 to 33 more patients per 1000]. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision, and strong suspicion of publication bias. Adjusted analysis from 1 of these studies (cohort study: Harjento 2016) showed similar survival to hospital admission with and without dispatch-assisted CPR being offered [ORadj 0.97 (0.70-1.34); RR: NA; ARR: NA; p=0.85]. The certainty of evidence was very low, downgraded for serious risk of bias and very serious imprecision.

Provision of Bystander CPR

For the critical outcome provision of bystander CPR we identified very low certainty evidence from 9 studies evaluating the effect of dispatch-assisted CPR (before-after studies: Culley 1991 362, Harjanto 2016 85, Song 2014 34, Stipulante 2014 177, Vaillancourt 2007 877, cohort studies: Hiltunen 2015, JCSRSSG 2013 2742, Akahane 2012 1410, Ro 2016 20).

The meta-analysis of unadjusted data for the provision of bystander CPR included 192734 out of hospital cardiac arrest patients and showed higher bystander CPR rates for patients that were offered dispatch-assisted CPR [OR 3.10 (2.25-4.25); RR 2.00 (1.77, 2.25); p<0.0001; 269/1000 more patients received bystander CPR with the intervention [95% CI 189 patients /1000 to 344 more patients per 1000] when compared with patients not offered dispatch-assisted CPR. The certainty of evidence was very low downgraded for serious risk of bias. Meta-analysis of adjusted data from 3 of these studies (before-after study: Song 2014 34, cohort studies: Fukushima 2015 e005058, Goto 2014 e000499) showed higher bystander CPR rates for patients offered dispatch-assisted CPR [ORadj 5.74 (2.40-13.72) RR: NA; ARR: NA ; p<0.0001] when compared with patients not offered dispatch-assisted CPR. The certainty of evidence was very low, downgraded for very serious risk of bias, upgraded for strong association. 

Initial shockable rhythm

For the important outcome of initial shockable rhythm we identified very low certainty evidence from 5 studies evaluating the effect of dispatch-assisted CPR (before-after studies: Harjanto 2016 85, Song 2014 34, Vaillancourt 2007 877, cohort studies: Takahashi 2017 384, Goto 2014 e000499). The meta-analysis of unadjusted data on initial shockable rhythm included 53371 out of hospital cardiac arrest patients and showed increased proportions of initial shockable rhythms in patients offered dispatch-assisted CPR [OR  1.13 (1.03-1.23); RR 1.08 (1.02, 1.14); p=0.007; 28/1000 more patients had initial shockable rhythm with the intervention [95% CI 13 more patients /1000 to 47 more patients per 1000] when compared with patients not offered dispatch-assisted CPR. The certainty of evidence was very low, downgraded for serious risk of bias, inconsistency and imprecision.

Time to bystander CPR

For the important outcome of time to bystander CPR we identified very low certainty evidence from 1 study (cohort study: Goto 2014 e000499) enrolling 4306 out of hospital cardiac arrest patients which showed shorter time to bystander CPR in patients offered dispatch-assisted CPR (median 4 min (inter quartile range 1-9); vs. 11 min (inter quartile range 7-16), p<0.0001) when compared with patients not offered dispatch-assisted CPR. The certainty of evidence was very low, downgraded for serious risk of bias.

Studies comparing outcomes from patients when dispatch-assisted CPR instruction was received with outcomes from patients when dispatch-assisted CPR instruction was not received

Fourteen studies compared outcomes among patients who received dispatch-assisted CPR with outcomes for patients who did not receive dispatch-assisted CPR (either patients who did not receive any bystander CPR or patients who received unassisted bystander CPR). Only 8 of these studies provided adjusted analysis for any of the critical or important outcomes. In general, the patients receiving dispatch-assisted CPR were different in important ways from patients not receiving any bystander CPR (generally patients with more unfavorable prognostic characteristics) and patients receiving unassisted (without dispatch assistance) bystander CPR (generally patients with more favorable prognostic characteristics). Accordingly, we only used data adjusted for important potential confounders in the development of the consensus on science and treatment recommendations. Meta-analysis of unadjusted data for all critical and important outcomes may be found in Table 1 and Table 2.  

Survival with good neurological function

For the critical outcome of survival with good neurological function at hospital discharge or 1 month, we identified very low certainty evidence from 5 studies evaluating the effect of dispatch-assisted CPR on a patient level (Discharge: Wu 2018 135, Ro 2017 52, Chang 2018 49; 1 month: Goto 2014 e000499, JCSRSSG 2013 2742).

Dispatch-assisted CPR vs. no bystander CPR:

The meta-analysis of adjusted data for survival with good neurological function at hospital discharge (Wu 2018 135, Ro 2017 52, Chang 2018 49) included 35921 out of hospital cardiac arrest patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.54 (1.35, 1.76); RR: NA; ARR: NA p<0.0001] when compared with patients who did not receive any bystander CPR. The certainty of evidence was very low, downgraded for serious risk of bias.   

Dispatch-assisted CPR vs. unassisted bystander CPR:

The adjusted analysis of survival with good neurological function at hospital discharge (Ro 2017 52) included 17209 out of hospital cardiac arrest patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.12 (0.94, 1.34); RR: NA; ARR: NA p<0.22] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision.

Dispatch-assisted CPR vs. no bystander CPR:

The adjusted analysis of survival with good neurological function at 1 month (Goto 2014 e000499) included 4306 out of hospital cardiac arrest patients patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.81 (1.23, 2.67) p=0.003] when compared with patients who did not receive any bystander CPR. The certainty of evidence was very low, downgraded for serious risk of bias.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The adjusted analysis of survival with good neurological function at 1 month (JCSRSSG 2013 2742) included 78112 out of hospital cardiac arrest patients and showed similar rates of survival with good neurological function at 1 month [ORadj 1.00 (0.91, 1.08); RR: NA; ARR: NA p=1] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias and serious imprecision.

Survival (hospital discharge or 1 month)

For the critical outcome of survival to hospital discharge or 1 month, we identified very low certainty evidence from 8 studies evaluating the effect of dispatch-assisted CPR on a patient level (Discharge: Wu 2018 135, Ro 2017 52, Shah 2017 222, Chang 2018 49, Rea 2001 2513, 1 month: Goto 2014 e000499, Viereck 2017 141, JCSRSSG 2013 2742).

Dispatch-assisted CPR vs. no bystander CPR:

The meta-analysis of adjusted data on survival to hospital discharge (Wu 2018 135, Ro 2017 52, Shah 2017 222, Chang 2018 49, Rea 2001 2513) included 43550 out of hospital cardiac arrest patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.40 (1.09, 1.78); RR: NA; ARR: NA p=0.008] when compared with patients who did not receive any bystander CPR. The certainty of evidence was very low, downgraded for serious risk of bias.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The analysis of adjusted data on survival to hospital discharge (Ro 2017 52) included 17209 out of hospital cardiac arrest patients and showed that patients who received dispatch assisted CPR had similar survival to hospital discharge [ORadj 0.95 (0.83, 1.09); RR: NA; ARR: NA p=0.46] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision.

Dispatch-assisted CPR vs. no bystander CPR:

The analysis of adjusted data on survival to 1 month (Goto 2014 e000499) included 4306 out of hospital cardiac arrest patients patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.63 (1.32, 2.01), p<0.0001] when compared with patients who did not receive any bystander CPR. The certainty of evidence was very low, downgraded for serious risk of bias.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The meta-analysis of adjusted data on survival to 1 month (Viereck 2017 141, JCSRSSG 2013 2742) included 78697 out of hospital cardiac arrest patients and showed benefit for patients who received dispatch-assisted CPR [OR 1.13 (1.06, 1.20), p=0.0003] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias.

Short term survival (sustained ROSC, ROSC at hospital admission)

For the critical outcome of sustained ROSC or ROSC at hospital admission, we identified very low certainty evidence from 4 studies evaluating the effect of dispatch-assisted CPR on a patient level (sustained ROSC: Ro 2017 52, Viereck 2017 141, Takahashi 2017 384; ROSC at hospital admission: JCSRSSG 2013 2742).

Dispatch-assisted CPR vs. no bystander CPR:

The adjusted analysis of data on sustained ROSC (Ro 2016 20) included 32506 out of hospital cardiac arrest patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.51 (1.32, 1.73); RR: NA; ARR: NA, p<0.001] when compared with patients who did not receive any bystander CPR. The certainty of evidence was very low, downgraded for serious risk of bias.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The meta-analysis of adjusted data on sustained ROSC (Ro 2017 52, Viereck 2017 141, Takahashi 2017 384) included 34811 out of hospital cardiac arrest patients and showed similar rates of sustained ROSC [ORadj 1.04 (0.94, 1.14); RR: NA; ARR: NA p=0.44] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias and imprecision.

Dispatch-assisted CPR vs. no bystander CPR:

No adjusted analysis was available to evaluate ROSC to hospital admission for patients who received dispatch-assisted CPR compared with patients who did not receive any bystander CPR.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The adjusted analysis of ROSC to hospital admission (JCSRSSG 2013 2742) included 78150 out of hospital cardiac arrest patients patients and showed benefit for patients who received dispatch-assisted CPR [ORadj 1.09 (1.04, 1.14), p<0.0003] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was very low, downgraded for serious risk of bias.

Initial shockable rhythm

For the important outcome of initial shockable rhythm we identified very low certainty evidence from 1 study evaluating the effect of dispatch-assisted CPR on a patient level (Takahashi 2017 384).

Dispatch-assisted CPR vs. no bystander CPR:

No adjusted analysis was available to evaluate initial shockable rhythm for patients who received dispatch-assisted CPR compared with patients who did not receive any bystander CPR.

Dispatch-assisted CPR vs. unassisted bystander CPR:

The adjusted analysis of initial shockable rhythm included 17054 out of hospital cardiac arrest patients and showed similar rates of initial shockable rhythm  [ORadj 1.02 (0.95, 1.09) RR: NA; ARR: NA p=0.57] when compared with patients who received bystander CPR without dispatch assistance. The certainty of evidence was downgraded for serious risk of bias and serious imprecision.

Time to CPR

For the important outcome of time to CPR, no adjusted data was identified.

Treatment Recommendations

We recommend that emergency medical dispatch centers have systems in place to enable call handlers to provide CPR instructions for adult patients in cardiac arrest. (strong recommendation, very-low-certainty evidence)

We recommend that emergency call takers provide CPR instructions (when required) for adult patients in cardiac arrest. (strong recommendation, very-low-certainty evidence)

Justification and EtD Highlights

  • Although reviewed for the 2015 Guidelines, this topic was given top priority by the Basic Life Support Task Force as an active area of research believed to be of great potential value in improving cardiac arrest outcomes.
  • The science evaluating the effect of dispatcher assisted CPR is complex as it compares outcomes for patients who have been offered or received dispatch assisted CPR to outcomes for both patients who receive no bystander CPR and patients who receive un-assisted bystander CPR. Taken together, we find these studies support dispatch-assisted CPR as outcomes are generally better for patients who receive dispatch-assisted CPR compared to no bystander CPR, and for some outcomes as good as unassisted bystander CPR. The Task Force placed a greater value on studies providing adjusted analysis as cohorts of patients who received unassisted CPR generally had more favourable prognostic characteristics, and cohorts of patients who did not receive any bystander CPR generally has less favourable prognostic characteristics.
  • Long term outcomes can be confounded by various factors along the chain of survival. The task force therefore included short-term outcomes such as increased rates of bystander CPR and initial shockable rhythms as relevant outcomes when making the treatment recommendations.
  • The Basic Life Support Task Force has made a strong recommendation despite very-low certainty evidence. This discordant recommendation is made as the task force acknowledges the significant challenges in increasing bystander CPR rates with traditional CPR training alone, and wishes to emphasize the dispatcher or call-takers potential to increase bystander CPR rates.  

Knowledge Gaps

In terms of providing high quality of care in emergency medical dispatch for cardiac arrest, there are important knowledge gaps regarding best methods to optimize initial training methodology, retraining frequency interval, and quality improvement programs. There were no studies identified that evaluated what the optimal instruction sequence for dispatch-assisted CPR should be, or any potential  impact of dispatcher or call-taker’s background (non-healthcare professional versus paramedic or nurse).

The role of new technologies in locating and distributing Automatic External Defibrillators and their interphase with bystander or lay rescuers and the emergency medical dispatch centers also needs to be explored. 

References

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Attachments

DACPR v Bystander Final Evidence to Decision tables

DACPR v No Bystander Final Evidence to Decision tables

EMS DACPR vs no EMS DACPR Final Evidence to Decision tables



CPR

Discussion

GUEST
Simon Gould
There are many variables in assessing dispatcher assisted CPR. This review does not take into account the nature of the advice vs the outcome i.e. ROSC, short term survival and survival to discharge i.e. compressions only (in the case of predominately cohorts of adult subjects or traditional compressions and ventilation CPR. Various studies have shown that compression-only CPR (as the primary scenario usually involves adults and is a SCA [>80%]) is as (or more) effective in producing favourable outcomes. Research in Sweden indicated compression-only instruction by Emergency Dispatchers/Calltakers resulted in a 75% increase in bystander willingness to commence resuscitation prior to ambulance arrival a factor not addressed in the review. In Australia (and no doubt other countries) ventilations are still part of dispatcher assisted CPR advice, despite no evidence that bystanders in an emergency (with or without training) can master both airway management and control of tidal volume to prevent aspiration. The is also significant barriers identified in research to the ability of non-clinical emergency calltakers to determine cardiac arrest i.e. an inability to correctly identify and recognise agonal respirations (in the absence of a response to pain) as indicative of SCA. This would further influence the accuracy of the outcomes reported. Although the presence or absence of “breathing” by a novice is extremely unlikely to be accurate nor to consider or recognise if the patient is “breathing normally”; the incorrect question (i.e. presence or absence of breathing) is still used by some emergency services (including Australia where there is a legacy and undying commitment to bystander ventilations despite evidence to the contrary in regard to efficacy). There is therefore doubt as to determining circumstances of an arrest as determined in reviewing the evidence and making assumptions. It is also a mistake in assuming bystanders are capable of effective ventilation and airway management and that will not result in gastric distension and aspiration (a significant cause of failure to survive to discharge due to aspiration pneumonia). This also applies to those trained in BLS, who must only be considered novices for the purposes of airway management and ventilation and not “trained individuals” as determined in other ILCOR documentation. Lastly it would be helpful to understand what formal consideration of public feedback is undertaken by the relevant ILCOR committees, prior to the release of treatment recommendations i.e. as to whether this input is just consultative or collaborative as in the past the drafts and final documents seem unchanged despite legitimate concerns about the utility and efficacy of the recommendations.
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