Is dispatcher-assisted cardiopulmonary resuscitation affected by a bystander's emotional stress state in out-of-hospital cardiac arrest?

AIM: The study aimed to investigate whether a bystander's emotional stress state affects dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) in out-of-hospital cardiac arrest (OHCA). The primary outcome was initiation of chest compressions (Yes/No). Secondarily we analysed time until chest compressions were initiated and assessed how dispatchers instructed CPR. METHOD: The study was a retrospective, observational study of OHCA emergency calls from the Capital Region of Denmark. Recorded calls were evaluated by five observers using a pre-defined code catalogue regarding the variables wished investigated. RESULTS: Included were 655 OHCA emergency calls, of which 211 callers were defined as emotionally stressed. When cardiac arrest was recognized, chest compressions were initiated in, respectively, 76.8% of cases with an emotionally stressed caller and 73.9% in cases with a not emotionally stressed caller (2.18 (0.80-7.64)). Cases with an emotionally stressed caller had a longer time until chest compressions were initiated compared to cases with a not emotionally stressed caller, however non-significant (164 s. vs. 146 s.; P = 0.145). The dispatchers were significantly more likely to be encouraging and motivating, and to instruct on speed and depth of chest compressions in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.64 (1.07-2.56); 1.78 (1.13-2.88)). Barriers to CPR were significantly more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.83 (1.32-2.56)). CONCLUSION: There was no significant difference in initiation of chest compressions or in time until initiation of chest compressions in the two groups. However, the dispatchers were overall more encouraging and motivating, and likely to instruct on speed and depth of chest compressions when the caller was emotionally stressed. Furthermore, barriers to CPR were more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller. TRIAL REGISTRATION: We applied for ethical approval from The Danish National Committee on Health Research Ethics, but formal approval was waived. We received permission for storage of data and to use these for research of OHCAs in the Capital Region of Denmark by Danish Data Protection Agency (P-2021-670) and Danish Health Authorities (R-2,005,114). The study is registered at ClinicalTrials (NTC05113706).

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study.

BACKGROUND: Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool. METHODS: In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups. RESULTS: There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization. CONCLUSION: Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome. TRIAL REGISTRATION: Clinicaltrials.gov.: Id NCT04074239. Registered 2019-08-30. https://clinicaltrials.gov/ct2/show/study/NCT04074239.

Video triage of children with respiratory symptoms at a medical helpline is safe and feasible-a prospective quality improvement study.

BACKGROUND: Young children are among the most frequent patients at medical call centers, even though they are rarely severely ill. Respiratory tract symptoms are among the most prevalent reasons for contact in pediatric calls. Triage of children without visual cues and through second-hand information is perceived as difficult, with risks of over- and under-triage. OBJECTIVE: To study the safety and feasibility of introducing video triage of young children with respiratory symptoms at the medical helpline 1813 (MH1813) in Copenhagen, Denmark, as well as impact on patient outcome. METHODS: Prospective quality improvement study including 617 patients enrolled to video or standard telephone triage (1:1) from February 2019-March 2020. Data originated from MH1813 patient records, survey responses, and hospital charts. Primary outcome was difference in patients staying at home eight hours after the call. Secondary outcomes weas hospital outcome, feasibility and acceptability. Adverse events (intensive care unit admittance, lasting injuries, death) were registered. Logistic regression was used to test the effect on outcomes. The COVID-19 pandemic shut the study down prematurely. RESULTS: In total, 54% of the included patients were video-triaged., and 63% of video triaged patients and 58% of telephone triaged patients were triaged to stay at home, (p = 0.19). Within eight and 24 hours, there was a tendency of fewer video-triaged patients being assessed at hospitals: 39% versus 46% (p = 0.07) and 41% versus 49% (p = 0.07), respectively. At 24 hours after the call, 2.8% of the patients were hospitalized for at least 12 hours. Video triage was highly feasible and acceptable (>90%) and no adverse events were registered. CONCLUSION: Video triage of young children with respiratory symptoms at a medical call center was safe and feasible. Only about 3% of all children needed hospitalization for at least 12 hours. Video triage may optimize hospital referrals and increase health care accessibility.

Improving survival after out-of-hospital cardiac arrest.

During the past 20 years the survival after out-of-hospital cardiac arrest (OHCA) has almost quadrupled from 4% in 2001 to 14% in 2020. There has been a huge focus on layman education in cardiopulmonary resuscitation and use of automated external defibrillators (AED), implementation of healthcare staff at 1-1-2 dispatch centers, early recognition of OHCA, establishment of a national AED register with publicly available AEDs, and dispatch of volunteer responders in case of nearby OHCA. This review describes implemented initiatives with the purpose of improving survival from OHCA in Denmark.

Introducing video calls in an intensive care unit during the COVID-19 lockdown: a qualitative study.

INTRODUCTION: During the first wave of the COVID-19 pandemic, visits to hospitals were prohibited. Therefore, new ways of communicating with relatives about and with patients were needed. This study aimed to explore experiences made with video calls in an adult ICU. METHODS: This study employed semi-structured group interviews conducted with six registered nurses from the ICU in a large hospital in Denmark who used video calls during the lockdown. Interviews were transcribed verbatim and analysed using systematic text condensation. RESULTS: The analyses indicated that video calls were a useful alternative to physical meetings. The advantages of video calls were that relatives had risk-free access to the ICU and the patient's treatment, whereas patients gained a window into their home, and nurses used less planning time than physical visit. Finally, patients were less distracted by video calls than by visits. The challenges identified with video calls were difficulties for nurses to care for relatives, ethical aspects and technical issues. CONCLUSIONS: Video calls were an effective tool for communication during the COVID-19 lockdown, presenting a number of advantages and challenges compared with in-person visits or telephone calls. By identifying and overcoming these challenges, video calls may become a beneficial supplement to in-person visits or telephone calls. FUNDING: none. TRIAL REGISTRATION: Approved by the Danish Data Protection Agency (P-2020-931).

"We can't do without it": Parent and call-handler experiences of video triage of children at a medical helpline.

BACKGROUND: Pediatric out-of-hours calls are common, as parents worry and seek reassurance and shared responsibility. Nevertheless, most children assessed in this context are not seriously ill. Conventional telephone triage lacks visual cues and is further limited by third part communication in calls concerning children. We investigated implementation of video triage in two previous studies. The aim of the present study was to investigate 1) How video triage versus telephone triage in children was experienced by parents and call-handlers, and 2) call-handlers' evaluation of the video triage projects. METHODS: We triangulated data from surveys and interviews in five sub-studies. Sub-study 1: Parents' experience of video triage reported in closed-ended questionnaire items using quantitative analysis; Sub-study 2: Parents' experience of video triage reported as questionnaire free-text using qualitative content analysis; Sub-study 3: Call-handlers' experience of video triage reported in closed-ended questionnaire items using quantitative analysis; and Sub-studies 4 and 5: Individual interviews of call-handlers' experience of 1) video triage using thematic analysis and 2) the video triage project using process evaluation. RESULTS: Most parents' comments regarding video triage were positive (n = 164, 83%). Video triage was perceived as reassuring and reducing the likelihood of misunderstandings and unnecessary hospital visits. Call-handlers experienced that video triage improved patient assessment and caller reassurance. Some call-handlers complained that the time allocated for study participation was inadequate and requested a more accessible video set-up. Both parents and call-handlers were significantly more satisfied and reassured after video triage than after telephone triage and suggested video triage as a permanent option. CONCLUSION: Video triage was appreciated by parents and call-handlers and was recommended as a permanent option. The call-handlers suggested that designated time for participation in the studies would have been desirable in this busy call-center. We recommend video triage as a contemporary solution in out-of-hours service.

Live video from bystanders' smartphones to improve cardiopulmonary resuscitation.

AIM: To investigate whether live video streaming from the bystander's smartphone to a medical dispatcher can improve the quality of bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA). METHODS: After CPR was initiated, live video was added to the communication by the medical dispatcher using smartphone technology. From the video recordings, we subjectively evaluated changes in CPR quality after themedical dispatcher had used live video to dispatcher-assisted CPR (DA-CPR). CPR quality was registered for each bystander and compared with CPR quality after video-instructed DA-CPR. Data were analysed using logistic regression adjusted for bystander's relation to the patient and whether the arrest was witnessed. RESULTS: CPR was provided with live video streaming in 52 OHCA calls, with 90 bystanders who performed chest compressions. Hand position was incorrect for 38 bystanders (42.2%) and improved for 23 bystanders (60.5%) after video-instructed DA-CPR. The compression rate was incorrect for 36 bystanders (40.0%) and improved for 27 bystanders (75.0%). Compression depth was incorrect for 57 bystanders (63.3%) and improved for 33 bystanders (57.9%). The adjusted odds ratios for improved CPR after video-instructed DA-CPR were; hand position 5.8 (95% CI: 2.8-12.1), compression rate 7.7 (95% CI: 3.4-17.3), and compression depth 7.1 (95% CI: 3.9-12.9). Hands-off time was reduced for 34 (37.8%) bystanders. CONCLUSIONS: Live video streaming from the scene of a cardiac arrest to medical dispatchers is feasible. It allowed an opportunity for dispatchers to coach those providing CPR which was associated with a subjectively evaluated improvement in CPR performance.

Live video from bystanders' smartphones to medical dispatchers in real emergencies.

BACKGROUND: Medical dispatchers have limited information to assess the appropriate emergency response when citizens call the emergency number. We explored whether live video from bystanders' smartphones changed emergency response and was beneficial for the dispatcher and caller. METHODS: From June 2019 to February 2020, all medical dispatchers could add live video to the emergency calls at Copenhagen Emergency Medical Services, Denmark. Live video was established with a text message link sent to the caller's smartphone using GoodSAM®. To avoid delayed emergency response if the video transmission failed, the medical dispatcher had to determine the emergency response before adding live video to the call. We conducted a cohort study with a historical reference group. Emergency response and cause of the call were registered within the dispatch system. After each video, the dispatcher and caller were given a questionnaire about their experience. RESULTS: Adding live video succeeded in 838 emergencies (82.2% of attempted video transmissions) and follow-up was possible in 700 emergency calls. The dispatchers' assessment of the patients' condition changed in 51.1% of the calls (condition more critical in 12.9% and less critical in 38.2%), resulting in changed emergency response in 27.5% of the cases after receiving the video (OR 1.58, 95% CI: 1.30-1.91) compared to calls without video. Video was added more frequently in cases with sick children or unconscious patients compared with normal emergency calls. The dispatcher recognized other or different disease/trauma in 9.9% and found that patient care, such as the quality of cardiopulmonary resuscitation, obstructed airway or position of the patient, improved in 28.4% of the emergencies. Only 111 callers returned the questionnaire, 97.3% of whom felt that live video should be implemented. CONCLUSIONS: It is technically feasible to add live video to emergency calls. The medical dispatcher's perception of the patient changed in about half of cases. The odds for changing emergency response were 58% higher when video was added to the call. However, use of live video is challenging with the existing dispatch protocols, and further implementation science is necessary.

Impact of dispatcher-assisted cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest: a systematic review.

BACKGROUND: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) increases neurologically intact survival in out-of-hospital cardiac arrest (OHCA) according to several studies. This systematic review summarizes neurologically intact survival outcomes of DA-CPR in comparison with bystander-initiated CPR and no bystander CPR in OHCA. METHODS: The systematic review was conducted according to the PRISMA guidelines. All studies including adult and/or pediatric OHCAs that compared DA-CPR with bystander-initiated CPR or no bystander CPR were included. Primary outcome was neurologically intact survival at discharge, one-month or longer. Studies were searched for in PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. The risk of bias was evaluated using the Newcastle-Ottawa Scale. RESULTS: The search string generated 4742 citations of which 33 studies were eligible for inclusion. Due to overlapping study populations, the review included 14 studies. All studies were observational. The study populations were heterogeneous and included adult, pediatric and mixed populations. Some studies reported only witnessed cardiac arrests, arrests of cardiac ethiology, and/or shockable rhythm. The individual studies scored between six and nine on the Newcastle-Ottawa Scale of risk of bias. The median neurologically intact survival at hospital discharge with DA-CPR was 7.0% (interquartile range (IQR): 5.1-10.8%), with bystander-initiated CPR 7.5% (IQR: 6.6-10.2%), and with no bystander CPR 4.4% (IQR: 2.0-9.0%) (four studies). At one-month neurologically intact survival with DA-CPR was 3.1% (IQR: 1.6-3.4%), with bystander-initiated CPR 5.7% (IQR: 5.0-6.0%), and with no bystander CPR 2.5% (IQR: 2.1-2.6%) (three studies). CONCLUSION: Both DA-CPR and bystander-initiated CPR increase neurologically intact survival compared with no bystander CPR. However, DA-CPR demonstrates inferior outcomes compared with bystander-initiated CPR. Early CPR is crucial, thus in cases where bystanders have not initiated CPR, DA-CPR provides an opportunity to improve neurologically intact survival following OHCA. Variability in OHCA outcomes across studies and multiple confounding factors were identified.

Challenges in out-of-hospital cardiac arrest - A study combining closed-circuit television (CCTV) and medical emergency calls.

UNLABELLED: The aim of this study was to explore challenges in recognition and initial treatment of out-of-hospital cardiac arrest (OHCA) by using closed-circuit television (CCTV) recordings combined with audio recordings from emergency medical calls. METHOD: All OHCA captured by CCTV in the Capital Region of Denmark, 15 June 2013-14 June 2014, were included. Using a qualitative approach based on thematic analysis, we focused on the interval from the victim's collapse to the arrival of the ambulance. RESULTS: Based on the 21 CCTV recordings collected, the main challenges in OHCA seemed to be situation awareness, communication and attitude/approach. Situation awareness among bystanders and the emergency medical dispatchers (dispatcher) differed. CCTV showed that bystanders other than the caller, were often physically closer to the victim and initiated cardiopulmonary resuscitation (CPR). Hence, information from the dispatcher had to pass through the caller to the other bystanders. Many bystanders passed by or left, leaving the resuscitation to only a few. In addition, we observed that the callers did not delegate tasks that could have been performed more effectively by other bystanders, for example, receiving the ambulance or retrieving an Automated External Defibrillator (AED). CONCLUSION: CCTV combined with audio recordings from emergency calls can provide unique insights into the challenges of recognition and initial treatment of OHCA and can improve understanding of the situation. The main barriers to effective intervention were situation awareness, communication and attitude/approach. Potentially, some of these challenges could be minimized if the dispatcher was able to see the victim and the bystanders at the scene. A team approach, with the dispatcher responsible for the role as team leader of a remote resuscitation team of a caller and bystanders, may potentially improve treatment of OHCA.

Dysejaculation after laparoscopic inguinal herniorrhaphy: a nationwide questionnaire study.

BACKGROUND: Dysejaculation and pain from the groin and genitals during sexual activity represent a clinically significant problem in up to 4% of younger males after open inguinal herniorrhaphy. The aim of this questionnaire study is to assess the prevalence of dysejaculation and pain during sexual activity after laparoscopic inguinal herniorrhaphy on a nationwide basis. METHODS: The study population comprised all men aged 18-50 years registered in the Danish Hernia Database (n = 1,671) who underwent primary laparoscopic herniorrhaphy between January 1, 1998 and November 30, 2009. Questionnaires regarding dysejaculation and pain during sexual activity were mailed 3 months to 12 years after surgery, and 1,172 patients were included for analysis. RESULTS: The response rate was 68.7% (n = 805). Dysejaculation occurring after laparoscopic repair was present in 25 patients (3.1%). Pain from the groin or genitals during sexual activity was reported by 88 patients (10.9%), and 19 patients (2.4%) reported that the pain had impaired their sexual activity to a moderate or severe degree. Older patients and patients with longer follow-up had lower prevalence of pain during sexual activity. CONCLUSIONS: Dysejaculation and pain-related impairment of sexual activity is a significant problem after laparoscopic inguinal herniorrhaphy. The role of improved laparoscopic technique with use of glue fixation of lightweight meshes to reduce the risk of developing these complications needs to be evaluated.

Short-term prognosis of community-acquired bacteremia in patients with liver cirrhosis or alcoholism: A population-based cohort study.

BACKGROUND: Liver cirrhosis is associated with an increased risk of infection and a poor prognosis, but the role of alcoholism in these outcomes is uncertain. This study looks at the short-term prognosis for bacteremia in patients with alcoholic liver cirrhosis, nonalcoholic liver cirrhosis, and alcoholism, compared with the prognosis for other bacteremia cases. METHODS: All patients who were hospitalized with their first community-acquired bacteremia in North Jutland County, Denmark, in the period 1992 to 2002 were retrieved from a population-based bacteremia registry. Denmark's Hospital Discharge Registry then allowed us to disaggregate these patients into the following groups: 47 patients with alcoholic liver cirrhosis, 19 with nonalcoholic liver cirrhosis, 190 with alcoholism, and a comparison group of 3,535 other bacteremia cases. Using logistic regression, we estimated odds ratios (ORs) for 30-day case fatality for the main study variable, adjusted for gender, age, focus of infection, and comorbidity. RESULTS: The case fatality rate (CFR) was 43% for patients with alcoholic liver cirrhosis, 32% for patients with nonalcoholic liver cirrhosis, 24% for patients with alcoholism, and 15% for other bacteremia patients. The adjusted OR estimates for patients with alcoholic liver cirrhosis, nonalcoholic liver cirrhosis, and alcoholism compared with other bacteremia cases were 6.3 (95% CI 3.3-11.7), 2.4 (95% CI 0.9-6.7), and 2.5 (95% CI 1.7-3.7), respectively. Focus of infection and group of bacteria did not noticeably affect the increased CFR. CONCLUSION: Liver cirrhosis and alcoholism were associated with a poor short-term prognosis for community-acquired bacteremia. Liver cirrhosis and alcoholism may have independent effects on the prognosis for patients with liver cirrhosis and bacteremia.