ILCOR Evidence Review

ILCOR Evidence Review Task Force BLS 19-Apr-13 Question Status Pending Evidence Collection Short Title Dispatch CPR instructions PICO Question Evidence Reviewers ;#34;#Christian Vaillancourt;#177;#Manya Charette;#309 Task Force Question Owner t-ann.wallinger@heart.org Among adults and children who are in cardiac arrest in any setting (P), does provision of dispatch CPR instructions (I), compared with no instructions (C), change survival to 30 days; survival with favorable neurologic ; survival to hospital discharge; delivery of bystander CPR; time to first shock; time to commence CPR; CPR parameters (O)? Search Inclusion and Exclusion Criteria Included comparative studies (prospective and retrospective), case series and reviews reporting on dispatcher-assisted cardiopulmonary resuscitation for adult and paediatric cardiac arrest. Excluded unpublished studies, and studies only published in abstract form, unless accepted for publication. Search Strategy PubMed (2000-current) Date searched: 01/10/2012 Result: 255 studies Therapy/Broad[filter] AND (("Out-of-Hospital Cardiac Arrest"[Mesh] OR "Heart Arrest"[Mesh] OR "Death, Sudden, Cardiac"[Mesh] OR "cardiopulmonary resuscitation/methods"[mesh] OR "cardiac arrest"[tiab] OR "cardiopulmonary resuscitation"[tiab] OR "cpr"[tiab]) AND ("dispatch*"[tiab] OR "telephone"[tiab] OR "calltaker"[tiab] OR "instruction*"[tiab] OR "Emergency Medical Services/organization and administration"[mesh])) AND (("2000/01/01"[PDAT] : "2013/12/31"[PDAT]) AND "humans"[mesh Terms]) Embase (via Embase.com 2000-current) Date searched: 01/10/12 Results: 411 studies 'out of hospital cardiac arrest'/exp OR 'cardiopulmonary resuscitation':ab,ti OR 'cpr':ab,ti OR 'cardiac arrest':ab,ti AND ('dispatch':ab,ti OR 'dispatcher':ab,ti OR 'dispatch-assisted':ab,ti OR 'telephone':ab,ti OR 'telephone-assisted':ab,ti) AND [2000-2013]/py Cochrane Central Register of led Trials (Central) via OVID (2000-current): Date searched: 01/10/12 Results: 182 studies (exp cardiopulmonary resuscitation/ or "resuscitation".ti,ab. or "cardiac arrest".ti,ab. or "cpr".ti,ab.) and (("dispatch*" or "telephone*").ti,ab. or exp emergency medical services/) Search Note Date Full Search Completed After search results from each database were combined, duplicate studies and reports of the same study in different journals were removed, 78 studies were further considered. Page 1 of 12

Newcastle-Ottawa Scale Reviews Question Dispatch CPR instructions Citation Akahane 2012 Reviewer Population Intervention Comparator 1780 pediatric OHCA, bystander witnessed, all rhythms Dispatcher CPR instructions No dispatcher CPR instruction s survival 1 month, OR 1,46, 95% CI 1,05-2,03, favourable neurological 1 month: OR 1,15, 95% CI 0,70-1,88 Commercial Funding Study Design Case- Case- Study Measures Case Cases c) No description a) Consecutive or obviously series a) From the same or similar the cases b) No description of source s b) Study controls for the most important factor and any additional factor d) Written self report or medical record only a) Same rate for both groups Cohort Study Measures nonexposed for s to Comments Citation Culley 1991 Reviewer Page 2 of 12

Population 260 OHCA Intervention Dispatch CPR Comparator No dispatch CPR s Survival, rate of bystander CPR Note Commercial Funding No Study Design Case- Case- Study Measures Case Cases, with independent validation a) Consecutive or obviously series a) From the same or similar the cases a) No history of disease or endpoint s c) Study does not control for the most important factor a) Secure record (eg surgical records) a) Same rate for both groups Cohort Study Measures nonexposed for s to Comments Citation Eisenberg 1985 Reviewer Population Intervention Comparator s Commercial Funding OHCA prior to EMS arrival, cardiac etiology, with CPR Telephone CPR training at dispatch centers Prior to telephone CPR training at dispatch centers CPR associated morbidity, survival to hospital admission, survival to hospital discharge No Page 3 of 12

Study Design Case- Case- Study Measures Case Cases, with independent validation a) Consecutive or obviously series a) From the same or similar the cases a) No history of disease or endpoint s a) Study controls for the most important factor a) Secure record (eg surgical records) b) Different, but non respondents described Cohort Study Measures nonexposed for s to Comments Citation Kuisma 2005 Reviewer Population 373, OHCA, witnessed VF cardiac origin, where resuscitation where attempted Intervention Dispatcher assisted CPR Comparator no dispatcher CPR s Survival to discharge; intervention 43,1% vs control 31,7% (p=0.0453) Witnessed VF OHCA, Dispatcher instructions in only 123 cases (35.5%) of calls Commercial Funding Study Design Case- Case- Study Measures Case Cases b) Yes, eg record linkage or based on self reports a) Consecutive or obviously series a) From the same or similar the cases a) No history of disease or endpoint s b) Study controls for the most important factor and any additional factor d) Written self report or medical record only a) Same rate for both groups Page 4 of 12

Cohort Study Measures nonexposed for s to Comments Citation Rea 2001 Reviewer Population Intervention Comparator s Commercial Funding 7265, OHCA, cardiac cause, > 18 years Dispatcher assisted CPR no dispatcher CPR Survival to hospital discharge, No bystander CPR as reference group: multivariate adjusted OR 1,45, 95% CI 1,21-1,73 for dispatcher assistance CPR and 1,69, 95% CI 1,42-2,01 for bystander CPR without dispatcher instructions Only cardiac causes to OHCA Study Design Case- Case- Study Measures Case Cases, with independent validation a) Consecutive or obviously series a) From the same or similar the cases a) No history of disease or endpoint s b) Study controls for the most important factor and any additional factor a) Secure record (eg surgical records) a) Same rate for both groups Cohort Study Measures nonexposed for s to Page 5 of 12

Comments Citation Tanaka 2012 Reviewer Population Intervention Comparator 1780, witnessed OHCA with cardiac etiology (1) and all OHCA (2), where resuscitation where attempted Dispatcher CPR no dispatcher CPR s (1) Survival 1 year intervention 35,7% vs control 22,8% (p=0.0243); Survival 1 year with favorable neurological intervention 27,8% vs control 16,3% (p=0.0276) (2) Survival 1 year with favorable neurological intervention 1.9% vs control 2,8% (p=0.0443) Commercial Funding evaluated a quality improvement program Study Design Case- Case- Study Measures Case Cases b) Yes, eg record linkage or based on self reports a) Consecutive or obviously series a) From the same or similar the cases a) No history of disease or endpoint s b) Study controls for the most important factor and any additional factor d) Written self report or medical record only a) Same rate for both groups Cohort Study Measures a) Truly of the community nonexposed a) Drawn from the same the exposed cohort for s to Comments Page 6 of 12

Citation Vaillancourt 2007 Reviewer Population Intervention Comparator 529, Witnessed OHCA Dispatcher assisted CPR no dispatcher CPR s Survival to discharge, intervention 3,0% vs control 4,8% 95% CI -5,0%-1,6%, (p=0.32) Commercial Funding Study Design Cohort Case- Study Measures Case Cases s Cohort Study Measures a) Truly of the community nonexposed a) Drawn from the same the exposed cohort a) Secure record (eg surgical records) b) Study controls for the most important factor and any additional factor b) Record linkage for s to a) Complete follow up Comments Page 7 of 12

Review of RCTs Included RCTs Quality Grid Included Articles Question Dispatch CPR instructions Akahane, Manabu; Ogawa, Toshio; Tanabe, Seizan; Koike, Soichi; Horiguchi, Hiromasa; Yasunaga, Hideo; Imamura, Tomoaki; Impact of telephone dispatcher assistance on the s of pediatric out-of-hospital cardiac arrest. Crit. Care Med. 2012; 40(5): 1410-6 Most previous studies of pediatric out-of-hospital cardiac arrest have typically examined relatively small datasets from small study regions. Although several studies have reported the impact on adult out-of-hospital cardiac arrest, little information is available on the impact of telephone dispatcher assistance on the s of pediatric out-of-hospital cardiac arrest. We set out to examine the impact of cardiopulmonary resuscitation instruction by telephone dispatcher on the s of pediatric out-of-hospital cardiac arrest. Population-based, observational study. Japan-wide population-based setting. We identified 1,780 pediatric out-of-hospital cardiac arrest patients (67.8% male) with witnessed collapse from a nationwide, population-based, outof-hospital cardiac arrest database. None. We assessed the impact of telephone dispatcher assistance on the s of 1- month survival rates and favorable neurologic status among the groups. The overall rate of bystander-performed chest compression and mouth-to-mouth ventilation among the witnessed pediatric out-of-hospital cardiac arrests were 39.5% and 25.6%, respectively. Telephone dispatcher assistance was offered in 28.4% of the witnessed pediatric out-of-hospital cardiac arrest cases and resulted in a significant increase in both chest compression (adjusted odds ratio 6.04; 95% confidence interval 4.72-7.72) and mouth-to-mouth ventilation (adjusted odds ratio 3.10; 95% confidence interval 2.44-3.95), and a significant improvement in 1-month survival rate (adjusted odds ratio 1.46; 95% confidence interval 1.05-2.03), but no significant effect on favorable neurologic s at 1 month (adjusted odds ratio 1.15; 95% confidence interval 0.70-1.88). Potential confounding factors included age categories, sex, bystander type, cause of cardiac arrest, bystander cardiopulmonary resuscitation, and attempted defibrillation. Telephone dispatcher assistance could significantly increase bystander cardiopulmonary resuscitation among witnessed pediatric out-of-hospital cardiac arrests. Although there was only a small, nonsignificant effect on the improvement in favorable neurologic at 1 month, the improved survival associated with telephone dispatcher assistance in pediatric out-of-hospital cardiac arrest is clinically important, and is of major public health importance. In cases where cardiac arrest was uncertain from the bystander's replies during the call to emergency medical services, telephone Page 8 of 12

dispatcher assistance was not offered, which could affect the adjusted odds ratio of the present study. PubMed ID 22430245 Culley, L; Clark, J; Eisenberg, M; Larsen, M; Dispatcher-assisted telephone CPR: common delays and time standards for delivery. Ann Emerg Med 1991; 20(4): 362-6 To determine the rate of bystander CPR before and after implementation of a telephone CPR program in King County; to determine the reasons for dispatcher delays in identifying patients in cardiac arrest in delivering CPR instructions over the telephone; and to suggest time standards for delivery of the telephone CPR message. An ongoing cardiac arrest surveillance system to calculate the annual bystander CPR rates from 1976 through 1988. Two hundred sixty-seven taped recordings of calls reporting cardiac arrests to nine emergency dispatch centers during 1988 were reviewed and timed. King County, Washington, excluding the city of Seattle. Two hundred sixty-seven persons with out-of-hospital cardiac arrests receiving emergency medical services. Arrests in doctors' offices, clinics, or nursing homes were excluded. Dispatcher-assisted telephone CPR. The rate of bystander CPR increased from 32% (1976 through 1981) to 54% (1982 through 1988) after implementation of the dispatcher-assisted telephone CPR program, although an increase in survival could not be demonstrated. The median time for dispatchers to identify the problem was 75 seconds; to deliver the early protocols, 19 seconds; to deliver the ventilation instructions, 25 seconds; and to deliver compression instructions, 30 seconds. The total time to deliver the entire CPR message was 2.3 minutes. The most frequent cause for delay was unnecessary questions (57%) with questions about patient age asked most frequently (32%). Other causes included the caller not being near the patient (29%) and deviations from protocol (22%). In a metropolitan emergency medical services system, a dispatcher-assisted telephone CPR program was associated with an increase in bystander CPR. Delays in proper delivery of telephone CPR can be minimized through training. PubMed ID 2003662 Eisenberg, M; Hallstrom, A; Carter, W; Cummins, R; Bergner, L; Pierce, J; Emergency CPR instruction via telephone. Am J Public Health 1985; 75(1): 47-50 We initiated a program of telephone CPR (cardiopulmonary resuscitation) instruction provided by emergency dispatchers to increase the percentage of bystander-initiated CPR for out-of-hospital cardiac arrest. Cardiac arrests in King County, Washington were studied for 20 months before and after the telephone CPR program began. Bystander-initiated CPR increased from 86 of 191 (45 per cent) cardiac arrests before the program to 143 of 255 (56 per cent) cardiac arrests after the program. During the after period, 58 patients received CPR as a result of telephone instruction, 12 of whom were discharged. We estimate that four lives may have been saved by the program. A review of hospital records revealed no excess morbidity in the group of patients receiving dispatcher-assisted CPR. Page 9 of 12

PubMed ID 3966598 Kuisma, Markku; Boyd, James; Väyrynen, Taneli; Repo, Jukka; Nousila-Wiik, Maria; Holmström, Peter; Emergency call processing and survival from out-of-hospital ventricular fibrillation. Resuscitation 2005; 67(1): 89-93 Our aim was to report the effect of the emergency call processing in the dispatching centre on survival from out-of-hospital ventricular fibrillation (VF). This retrospective cohort study was conducted in Helsinki Emergency Medical Services. All consecutive cases with out-of-hospital bystander witnessed VF of cardiac origin between 1 January 1997 and 31 December 2002 were included. Data were collected prospectively. Call processing times, call numbers per dispatcher and telephone guided cardiopulmonary resuscitation (CPR) were studied. Discharge alive from hospital was used as primary end point. The study population consisted of 373 cases. Cardiac arrest (CA) was recognised in 296 cases (79.4%) by the dispatcher. Survival to discharge was 37.2% (110/296) if CA was recognised and 28.6% (22/77) if it was not recognised (p=0.1550). When the dispatcher handled <4 VF calls during the study period survival to discharge was 22.1% (17/77) compared to 38.2% (50/131) and 39.4% (65/165) when the call volume was 4-9 or >9 (p=0.0227). The mean time to dispatch a first responding unit (FRU) was 77.1+/-44.3 s. Survival to discharge was 39.4% (65/165) when the FRU dispatching time was <60s and 32.2% (67/208) when dispatching took > or =60 s (p=0.1496). The mean time to CA recognition was 170.2+/-130.1 s. Spontaneous circulation was achieved more rapidly when the time was <150 s (p=0.0426), but there was no difference in survival to discharge. Telephone guided CPR instructions were given in 123 cases (35.5%). Survival to discharge was 43.1% (53/123) when CPR instructions were given and 31.7% (72/223) when they were not given (p=0.0453). We showed that low CA call numbers per dispatcher is associated with a decreased probability of survival. Giving telephone guided CPR instructions should be promoted as they influence the. Further studies are needed to determine optimal call processing times. PubMed ID 16129542 Rea, T; Eisenberg, M; Culley, L; Becker, L; Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation 2001; 104(21): 2513-6 Early cardiopulmonary resuscitation (CPR) improves survival in out-of-hospital cardiac arrest, and dispatcher-delivered instruction in CPR can increase the proportion of arrest victims who receive bystander CPR before emergency medical service (EMS) arrival. However, little is known about the survival effectiveness of dispatcher-delivered telephone CPR instruction. We evaluated a population-based cohort of EMS-attended adult cardiac arrests (n=7265) from 1983 through 2000 in King County, Washington, to assess the association between survival to hospital discharge and 3 distinct CPR groups: no bystander CPR before EMS arrival (no bystander CPR), bystander CPR before EMS arrival requiring dispatcher instruction (dispatcherassisted bystander CPR), and bystander CPR before EMS arrival not requiring dispatcher instruction (bystander CPR without dispatcher assistance). In this cohort, 44.1% received no bystander CPR before EMS arrival, 25.7% received dispatcher- Page 10 of 12

assisted bystander CPR, and 30.2% received bystander CPR without dispatcher assistance. Overall survival was 15.3%. Using no bystander CPR as the reference group, the multivariate adjusted odds ratio of survival was 1.45 (95% confidence interval [CI], 1.21, 1.73) for dispatcher-assisted bystander CPR and 1.69 (95% CI, 1.42, 2.01) for bystander CPR without dispatcher assistance. Dispatcher-assisted bystander CPR seems to increase survival in cardiac arrest. PubMed ID 11714643 Tanaka, Yoshio; Taniguchi, Junro; Wato, Yukihiro; Yoshida, Yutaka; Inaba, Hideo; The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the s of out-of-hospital cardiac arrests. Resuscitation 2012; 83(10): 1235-41 In 2007, the Ishikawa Medical Council initiated the continuous quality improvement (CQI) project for telephone-assisted cardiopulmonary resuscitation (telephone-cpr), which included instruction on chest-compression-only CPR, education on how to recognise out-of-hospital cardiac arrests (OHCAs) with agonal breathing, emesis and convulsion, recommendations for online or redialling instructions and feedback from emergency physicians. This study aimed to investigate the effect of this project on the incidence of bystander CPR and the s of OHCAs. The baseline data were prospectively collected on 4995 resuscitation-attempted OHCAs, which were recognised or witnessed by citizens rather than emergency medical technicians during the period of February 2004 to March 2010. The incidence of telephone-cpr and bystander CPR, as well as the s of the OHCAs, was compared before and after the project. The incidence of telephone-cpr and bystander CPR significantly increased after the project (from 42% to 62% and from 41% to 56%, respectively). The incidence of failed telephone-cpr due to human factors significantly decreased from 30% to 16%. The s of OHCAs significantly improved after the projects. A multiple logistic regression analysis revealed that the CQI project is one of the independent factors associated with one-year (1-Y) survival with favourable neurological s (odds ratio=1.81, 95% confidence interval=1.20-2.76). The CQI project for telephone-cpr increased the incidence of bystander CPR and improved the of OHCAs. A CQI project appeared to be essential to augment the effects of telephone-cpr. Copyright 2012 Elsevier Ireland Ltd. All rights reserved. PubMed ID 22366353 Vaillancourt, Christian; Verma, Aikta; Trickett, John; Crete, Denis; Beaudoin, Tammy; Nesbitt, Lisa; Wells, George; Stiell, Ian; Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions. Acad Emerg Med 2007; 14(10): 877-83 Page 11 of 12

To determine the frequency of agonal breathing during cardiac arrest (CA), its impact on the ability of 9-1-1 dispatchers to identify CA, and the impact of dispatch-assisted cardiopulmonary resuscitation (CPR) instructions on bystander CPR rates. A before-after observational study enrolling out-of-hospital adult CA patients where resuscitation was attempted in a single city with basic life support with defibrillation/advanced life support tiered emergency medical services. Victim, caller, and system characteristics were measured during two successive nine-month periods before (control group) and after (intervention group) the introduction of dispatch-assisted CPR instructions. There were 529 CAs between July 1, 2003, and December 31, 2004. Victim characteristics were similar in the control (n = 295) and intervention (n = 234) period; mean age was 68.3 years; 66.7% were male; 50.1% of CAs were witnessed; call-to-vehicle stop was 6 minutes, 37 seconds; ventricular fibrillation/ventricular tachycardia occurred in 29.9%; and the survival rate was 4.0%. Dispatchers identified 56.3% (95% confidence interval [CI] = 48.9% to 63.0%) of CA cases; agonal breathing was present in 37.0% (95% CI = 30.1% to 43.9%) of all CA cases and accounted for 50.0% (95% CI = 39.1% to 60.9%) of missed diagnoses. Callers provided ventilations in 17.2% and chest compressions in 8.3% of cases as a result of the intervention. Long time intervals were observed between call to diagnosis (2 minutes, 38 seconds) and during ventilation instructions (2 minutes, 5 seconds). Bystander CPR rates increased from 16.7% in the control phase to 26.4% in the intervention phase (absolute rate, 9.7%; 95% CI = 8.5% to 11.3%; p = 0.006). This trial demonstrates an increase in bystander CPR rate after the introduction of dispatch-assisted CPR. Agonal breathing occurred frequently and had a negative impact on the recognition of CA. There were long time intervals between call initiation and diagnosis of CA and during mouth-to-mouth ventilation instructions. PubMed ID 17761545 Excluded Articles Page 12 of 12