Clinical paperA before–after interventional trial of dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital cardiac arrests in Singapore☆
Introduction
Out-of-hospital cardiac arrest (OHCA) refers to sudden cessation of a heartbeat that happens outside the hospital, as evidenced by the absence of signs of circulation. Mortality is high with OHCA and it is a major public health issue affecting approximately 275,000 people in Europe,1 and between 350,200 and 368,200 people in the United States each year.2 Singapore currently has about 1500 OHCA yearly3 with the survival-to-hospital-discharge rate of only 3.0%.4 This is significantly lower than the 16.3% reported survival rates in Seattle, United States, as well as the 8.4% median survival rates in North America.5
Survival in OHCA depends heavily on a set of sequentially coordinated resuscitative interventions known as the Chain of Survival.6 Early Bystander Cardio-Pulmonary Resuscitation (BCPR) clearly improves the survival in OHCA.7, 8, 9 However, the current reported BCPR rate of 20.3% in Singapore10 is much lower than the rates of 31–55% reported in other parts of the world.11, 12, 13 This is despite widespread efforts in community education and CPR training. It has been shown that some of the barriers that discourage bystanders from performing CPR include difficulty in identifying a cardiac arrest, fear of causing injuries, emotional distress, and reluctance to perform mouth-to-mouth resuscitation.14 While such issues can be addressed with large-scale continual recertification programs, it is labor and cost intensive.
A new interventional strategy to improve the BCPR rate and OHCA survival has emerged in recent years. Such an intervention is known by several names such as telephone-assisted CPR, telephone-guided CPR or dispatcher-assisted CPR (DACPR). DACPR allows for early recognition of cardiac arrest and timely provision of BCPR through the questions asked and CPR pre-arrival instructions by a trained dispatcher. The 2010 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care suggest that bystanders should immediately call their local emergency response number when they find an unresponsive patient and that all dispatchers should be trained to provide CPR pre-arrival instructions.15 The 2010 International Liaison Committee on Resuscitation and European Resuscitation Council guidelines concurred with AHA's recommendation on dispatcher's recognition of cardiac arrest and providing CPR instructions before arrival of ambulance.16, 17 DACPR has also been made simpler with the change in recommendations to perform compression-only CPR for adults.
With a compression-only protocol, DACPR has also been shown to cause less delay in starting CPR, higher participation rate and better outcomes in early cardiac arrest.18 There is minimal risk associated with DACPR even when it is performed on collapsed patient who does not have a cardiac arrest. In a study done in Seattle, among 247 non-cardiac arrest patients who received DACPR, 2% had a rib fracture and none had any internal organ injury.19 In Ontario, Canada, implementation of DACPR has been successful in nearly doubling the rate of BCPR,20 which is the single most important modifiable factor influencing the survival in OHCA.21 In Singapore, where the population is served by a single dispatch centre of about 40 dispatchers, providing DACPR training to the group of dispatchers can have a far reaching impact on the population.
In this study, we perform an initial program assessment to measure the impact of a comprehensive DACPR training program, which is targeted at the dispatchers, on the rate of BCPR in Singapore. The secondary objectives for this study were to assess impact on survival, and compare the outcomes of patients who received DACPR to those who received conventional BCPR without dispatcher's assistance. We hypothesize that the implementation of the comprehensive DACPR training program will significantly increase the rate of BCPR for OHCA patients in Singapore compared to historical controls in a before–after analysis.
Section snippets
Methods
This is an initial program assessment to measure the impact in Singapore of implementing a comprehensive national DACPR training program on BCPR rates. The DACPR intervention is also part of an ongoing international multi-center trial.22 A before–after analysis was conducted to compare the various outcomes before and after the implementation of a comprehensive DACPR training program that consists of:
- (1)
A standardized dispatch protocol that will guide dispatchers to systematically question callers
Results
A total of 4121 OHCA cases from the Singapore (PAROS) registry, spanning from April 2010 to February 2013, were extracted. 3019 cases with presumed cardiac etiology were included. After excluding 13 cases with DNAR orders and 38 cases where resuscitation was not attempted by the EMS, 2968 cases remained to be included in the final dataset for analysis. There are 1820 cases in the BEFORE period, 475 cases in the RUN-IN period and 673 cases in the AFTER period (Fig. 1).
The characteristics of the
Discussion
This is an initial program evaluation of a national DACPR intervention in Singapore. The intervention appears to have positive effects towards an increased rate of BCPR and ROSC. It is noteworthy to mention that there was no special effort to step up public awareness or CPR training in Singapore throughout the period of this study. Survival to admission and survival at 30 days post-arrest have shown trends of improvement over the three study periods but have yet to achieve statistical
Conclusion
Significant increase in bystander CPR and ROSC was observed after the implementation of the comprehensive DACPR training program in Singapore. Survival to admission and at 30 days post cardiac arrest showed an increasing trend although did not reach statistical significance. BCPR from a trained bystander has the best outcomes, but DACPR has potential to improve outcomes when an untrained bystander is present, or there is reluctance to start CPR.
Conflict of interest statement
A/Prof Ong has licensing agreement and patent filing (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled ‘Method of predicting acute cardiopulmonary events and survivability of a patient’. No further conflict of interests for other authors.
Acknowledgements
The author would like to thank Ms Susan Yap, Mr Winston Teo, Mr Yazid from the Department of Emergency Medicine, Singapore General Hospital, and Ms Siti Zarinah from Singapore Civil Defence Force for their enormous help and support rendered in the course of gathering the necessary data for the study.
This study was supported by grants from National Medical Research Council, Clinician Scientist Award, Singapore (NMRC/CSA/024/2010), Ministry of Health, Health Services Research Grant, Singapore (
References (34)
- et al.
Incidence of EMS-treated out-of-hospital cardiac arrest in Europe
Resuscitation
(2005) - et al.
Heart disease and stroke statistics—2013 update: a report from the American Heart Association
Circulation
(2013) Proposal for establishment of a national sudden cardiac arrest registry
Singapore Med J
(2011)- et al.
Interventional strategies associated with improvements in survival for out-of-hospital cardiac arrests in Singapore over 10 years
Resuscitation
(2015) - et al.
Regional variation in out-of-hospital cardiac arrest incidence and outcome
JAMA
(2008) - et al.
Part 9: Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
Circulation
(2010) - et al.
Increases in survival from out-of-hospital cardiac arrest: a five year study
Resuscitation
(2013) - et al.
Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan
Circulation
(2012) - et al.
Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest
JAMA
(2013) - et al.
Geographic factors are associated with increased risk for out-of hospital cardiac arrests and provision of bystander cardio-pulmonary resuscitation in Singapore
Resuscitation
(2014)
New treatment bundles improve survival in out-of-hospital cardiac arrest patients: a historical comparison
Resuscitation
The impact of television public service announcements on the rate of bystander CPR
Prehosp Emerg Care
CPR instruction by videotape: results of a community project
Ann Emerg Med
Why bystanders decline telephone cardiac resuscitation advice
Acad Emerg Med
Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
Circulation
Part 1: Executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Circulation
European resuscitation council guidelines for resuscitation 2010 section 1. Executive summary
Resuscitation
Cited by (68)
Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim
2023, Emergency Medicine Clinics of North AmericaEfficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition
2021, American Journal of Emergency MedicineCitation Excerpt :The results of our study showed that V-DACPR could be implemented safely under the current dispatching system by transitioning audio calls to video calls using a controlled protocol and that the caller could perform better quality bystander CPR by receiving real-time feedback from the dispatcher. C-DACPR has been utilized to help the lay person perform CPR and is known to improve the rate of bystander CPR [5,6,19-21]. However, there is a limitation in the efficacy of C-DACPR because of poor compliance with dispatcher instructions due to factors such as inexperience in CPR, lack of training, old age, panicking, and instruction misunderstanding [9,10].
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.02.014.