National and State Efforts Further the Cause of TCPR

The public image of the firefighter or paramedic crew arriving on scene after a loud lights-and-siren journey across town is seen by many as the first act of responding heroism in saving a life. But the remote and calmer environment of the public safety answering point (PSAP) is the place where, in the case of cardiac arrest, information encouragement and reinforcement to push hard and fast is dispensed well ahead of another first responder on scene. Every visitor to the Richmond Ambulance Authority communications center receives a clear understanding that lifesaving begins with the phone call.

This fact is further brought home when, after a successful save, the inevitable survivor reunion takes place. In this event the strongest bond that forms is not between the survivor and first responders who defibrillated and transported them, but between the call-taker and bystander who called 9-1-1. Those two individuals shared an intimate five minutes where there was no one else in the world but a potentially dead person, often a relative, and a feeling of general helplessness. The direction and positive reinforcement of the 9-1-1 call-taker ultimately turned the lonely, panic-stricken caller into a good Samaritan. Only at the reunion are a name and face put to the voice that saved a life down the phone line.

At PSAPs where telephone CPR (TCPR) occurs, time, training and investment in some sort of question/answer and protocol system have taken place. But what of those who can’t currently offer more of an answer than “the ambulance is on its way”? Sadly these locales exist, and they are the target of the American Heart Association’s current comment period on its proposed dispatcher-assisted CPR standards.

Promoting the standards for the AHA is Michael Kurz, MD, associate professor of emergency medicine at the University of Alabama at Birmingham. As chair of the AHA’s telephone CPR task force, Kurz is blunt about the need for all to adopt the standards to deliver the earliest possible CPR: “The heart has stopped, and the brain doesn’t care, the pulseless person doesn’t care—all they care about is when they get their compressions,” he says.

Standards of Excellence

In Virginia further encouragement for the adoption of dispatching standards comes via the state’s Standards of Excellence (SOE) program. SOE was created to allow agencies and departments to raise their own bar in terms of corporate, operational and clinical governance. The program, basically a self-evaluation checklist of practices and procedures, allows departments to assess themselves against competency areas. For departments that wish to elevate themselves for state recognition, a site visit and evidence of practice scrutiny are required. Lack of rural attention to EMS and the delivery of telephone CPR was the main reason emergency medical dispatch, including the requirement for dispatch life support, was added to the SOE program.

The addition has allowed the SOE document to become a point of reference that highlights the lack of this essential link in the chain of survival when reporting back to local governing bodies. As this will inevitably lead to requests for funding and efforts to convince local officials, it is a much-needed report.

To convince localities to establish a standard for call-taking, dispatch and life support, the argument that surrounding localities employ systems is also valid. There is now a view that says not having these processes in place is no longer the standard of care and could lead to litigation if a patient who could have had a telephone intervention dies from being the wrong side of a county line.

Enabling the Have-Nots

The AHA standards and associated assistance package will quickly enable the have-nots to have. Once established, a quality program can then assess the uptick in quality and lives saved. As Kurz observes, “Centers can quickly put in place processes to measure the interval between first call and first compression—minutes matter in rural areas with long response times, and TCPR can expedite the commencement of lifesaving. No one should fall victim to OHCA in the U.S. and not receive bystander CPR instructions.”

The proposed AHA standards lay out the following requisites:

• Emergency communications center and dispatch center directors must commit to effective dispatcher-provided CPR;

• Dispatchers will train to give effective CPR instructions by phone and retrain to maintain and update skills;

• Implement quality improvement efforts that include analysis of all calls with confirmed cardiac arrests and resuscitation attempts;

• Evaluate dispatcher performance based on measures such as the percentage of cardiac arrest cases correctly identified; the percentage of victims who receive dispatcher-assisted CPR; and how long it takes for the dispatcher to recognize a cardiac arrest and CPR to begin.

Conclusion

There is no downside to telephone CPR/dispatch life support—it should be the standard of care whether the PSAP is run by EMS, law enforcement or a third party. If your locality is not doing this right now, call them and ask them to stay on the line as you tell them what to do next.

The Virginia Standards of Excellence program is free for all to use as a governance tool and can be found at www.vdh.virginia.gov/OEMS/Files_Page/Agency/StandardsOfExcellence.pdf.

The comment period for the AHA standards is open now and can be accessed at https://americanheart.co1.qualtrics.com/SE/?SID=SV_cOe0kgCjWFeMVyl&Q_JFE=0.

Rob Lawrence is chief operating officer of the Richmond Ambulance Authority.