Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis.

OBJECTIVE: In recent years, the costs of epinephrine autoinjectors (EAIs) in the United States have risen substantially. King County Emergency Medical Services implemented the "Check and Inject" program to replace EAIs by teaching emergency medical technicians (EMTs) to manually aspirate epinephrine from a single-use 1 mg/mL epinephrine vial using a needle and syringe followed by prehospital intramuscular administration of the correct adult or pediatric dose of epinephrine for anaphylaxis or serious allergic reaction. Treatment was guided by an EMT protocol that required a trigger and symptoms. We sought to determine if the "Check and Inject" program was safely implemented by EMTs treating presumed prehospital anaphylaxis or serious allergic reaction. METHODS: We conducted a prospective investigation of all cases treated as part of the "Check and Inject" program from July 2014 through December 2016 in suburban King County, Washington, and January 2016 through December 2016 within the city of Seattle. All cases were prospectively collected using a custom quality improvement data form completed by the first responding EMTs. Two physicians completed a structured review of each EMS medical record to determine if the EMTs followed the Check and Inject protocol and determine if epinephrine was clinically-indicated based on physician review. RESULTS: Of the 411 cases eligible for analysis, EMTs followed the protocol appropriately in 367 (89.3%) cases. In the remaining 44 (10.7%) cases, the EMS incident report form failed to document either a clear inciting allergic trigger or an appropriate symptom from the protocol list. Physician review determined that epinephrine was clinically indicated in 36 of the 44 cases. Among the remaining 8 cases (1.9%) that did not meet protocol criteria and were not clinically-indicated based on physician review, none had a documented adverse reaction to the epinephrine. CONCLUSION: We observed that EMTs successfully implemented the manual "Check and Inject" program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues.

Strategy to Address Private Location Cardiac Arrest: A Public Safety Survey.

OBJECTIVE: Most cardiac arrests occur in the private setting where response is often delayed and outcomes are poor. We surveyed public safety personnel to determine if they would volunteer to respond into private locations and/or be equipped with a personal automated external defibrillator (AED) as part of a vetted responder program that would use smart geospatial technology. METHODS: We conducted an anonymized survey among personnel from fire-based emergency medical services (EMS) and search and rescue organizations from Washington State. The goal of the survey was to evaluate whether there was interest among cardiopulmonary resuscitation (CPR)-trained, public safety personnel to respond with or without an AED to private-residence cardiac arrest outside of working hours using a smartphone platform. We used a 5-point Likert scale to assess responses. RESULTS: Overall the response rate was 73.7% (527/715). Two-thirds of respondents were between the ages of 30-59 with a similar proportion certified as a firefighter-emergency medical technician (EMT). Most were male (80%). As a vetted volunteer responder, the majority would "almost always" or "often" respond to private (79.7%) or public locations (85.2%) outside of work hours. The majority (54.1%) would store the AED in their vehicle while 38% would plan to keep the AED on their person. A total of 83% were "definitely' or "probably interested" in participating in the program. CONCLUSION: The results of this survey indicate that public safety personnel are willing to respond to suspected cardiac arrest during off-hours using geospatial smart technology to private locations with or without an AED.

Dispatcher-assisted cardiopulmonary resuscitation: time to identify cardiac arrest and deliver chest compression instructions.

BACKGROUND: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR), in which 9-1-1 dispatchers provide CPR instructions over the telephone, has been shown to nearly double the rate of bystander CPR. We sought to identify factors that hampered the identification of cardiac arrest by 9-1-1 dispatchers and prevented or delayed the provision of dispatcher-assisted CPR chest compressions. METHODS AND RESULTS: We reviewed dispatch recordings for 476 out-of-hospital cardiac arrests occurring between January 1, 2011, and December 31, 2011. We found that the dispatcher correctly identified cardiac arrest in 80% of reviewed cases and 92% of cases in which they were able to assess patient consciousness and breathing. The median time to recognition of the arrest was 75 seconds. Chest compressions following dispatcher-assisted CPR instructions occurred in 62% of cases when the dispatcher had the opportunity to asses for consciousness and breathing and bystander CPR was not already started. The median time to first dispatcher-assisted CPR chest compression was 176 seconds. CONCLUSIONS: Dispatchers are able to accurately diagnose cardiac arrest over the telephone, but recognition is likely not possible in all circumstances. In some cases, recognition of cardiac arrest may be improved through training in the detection of agonal respirations. Delays in the delivery of dispatcher-assisted CPR chest compressions are common and are attributable to a mixture of dispatcher behavior and factors beyond the control of the dispatcher. Performance standards for the successful and quick recognition of cardiac arrest and delivery of first chest compressions should be adopted as metrics against which emergency medical services systems can measure their performance.

Chest compression alone cardiopulmonary resuscitation is associated with better long-term survival compared with standard cardiopulmonary resuscitation.

BACKGROUND: Little is known about the long-term survival effects of type-specific bystander cardiopulmonary resuscitation (CPR) in the community. We hypothesized that dispatcher instruction consisting of chest compression alone would be associated with better overall long-term prognosis in comparison with chest compression plus rescue breathing. METHODS AND RESULTS: The investigation was a retrospective cohort study that combined 2 randomized trials comparing the short-term survival effects of dispatcher CPR instruction consisting either of chest compression alone or chest compression plus rescue breathing. Long-term vital status was ascertained by using the respective National and State death records through July 31, 2011. We performed Kaplan-Meier method and Cox regression to evaluate survival according to the type of CPR instruction. Of the 2496 subjects included in the current investigation, 1243 (50%) were randomly assigned to chest compression alone and 1253 (50%) were randomly assigned to chest compression plus rescue breathing. Baseline characteristics were similar between the 2 CPR groups. During the 1153.2 person-years of follow-up, there were 2260 deaths and 236 long-term survivors. Randomization to chest compression alone in comparison with chest compression plus rescue breathing was associated with a lower risk of death after adjustment for potential confounders (adjusted hazard ratio, 0.91; 95% confidence interval, 0.83-0.99; P=0.02). CONCLUSIONS: The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult patients with cardiac arrest requiring dispatcher assistance.

Treatment of cardiac arrest with rapid defibrillation by police in King County, Washington.

BACKGROUND: Improving survival from out-of-hospital cardiac arrest is an ongoing challenge for emergency medical services (EMS). Various strategies for shortening the time from collapse to defibrillation have been used, and one is to equip police officers with defibrillators. Objective. We evaluated the programmatic implementation of police defibrillation to determine if such a program could improve the process of care in a high-functioning and mature EMS system. METHODS: We conducted a prospective observational study of implementation of a police defibrillation in two police departments in King County, Washington, from March 1, 2010 to March 31, 2012. The program was designed to dispatch police specifically to cases with a high suspicion of cardiac arrest, defined as a patient who was unconscious and not breathing normally. We included all nontraumatic out-of-hospital cardiac arrest events that occurred prior to EMS arrival and within the city limits of the two cities. We collected both EMS and police dispatch reports to document times of call receipt, dispatch, and arrival of both agencies. We obtained rhythm recordings when the automated external defibrillators (AEDs) were used by the police. Descriptive statistics were used to measure frequency of police dispatch and to compare times to treatment between patients with a police response and those without. RESULTS: During the study period there were 231 cases of cardiac arrest that occurred prior to EMS arrival eligible for police response in the study communities. Police were dispatched to 124 (54%) of these cases. Of the 124, the police arrived before EMS 37 times, or 16% of the 231 cases. Police performed CPR in 29 of these cases and applied the AED in 21 of them. Of the 21 cases in which the AED was applied for cardiac arrest, a shock was delivered on first analysis for 6 patients. Although the response interval between dispatch to scene arrival was similar for EMS and police (4.5 minutes versus 4.6 minutes respectively, p = 0.08), police were dispatched considerably slower than EMS (1.8 minutes versus 0.6 minutes, p < 0.001). CONCLUSIONS: In the current programmatic implementation, police had a measurable but limited involvement in resuscitation. Efforts to address dispatch challenges may improve police involvement.

Pediatric Out-of-Hospital Cardiac Arrest: The Role of the Telecommunicator in Recognition of Cardiac Arrest and Delivery of Bystander Cardiopulmonary Resuscitation.

BACKGROUND: Telecommunicator CPR (T-CPR), whereby emergency dispatch facilitates cardiac arrest recognition and coaches CPR over the telephone, is an important strategy to increase early recognition and bystander CPR in adult out-of-hospital cardiac arrest (OHCA). Little is known about this treatment strategy in the pediatric population. We investigated the role of T-CPR and related performance among pediatric OHCA. METHODS AND RESULTS: This study was a retrospective cohort investigation of OHCA among individuals <18 years in King County, Washington, from April 1, 2013, to December 31, 2019. We reviewed the 911 audio recordings to determine if and how bystander CPR was delivered (unassisted or T-CPR), key time intervals in recognition of arrest, and key components of T-CPR delivery. Of the 185 eligible pediatric OHCAs, 23% (n=43) had bystander CPR initiated unassisted, 59% (n=109) required T-CPR, and 18% (n=33) did not receive CPR before emergency medical services arrival. Among all cases, cardiac arrest was recognized by the telecommunicator in 89% (n=165). Among those receiving T-CPR, the median (interquartile range) interval from start of call to OHCA recognition was 59 seconds (38-87) and first CPR intervention was 115 seconds (94-162). When stratified by age (≤8 versus >8), the older age group was less likely to receive CPR before emergency medical services arrival (88% versus 69%, P=0.002). For those receiving T-CPR, bystanders spent a median of 207 seconds (133-270) performing CPR. The median compression rate was 93 per minute (82-107) among those receiving T-CPR. CONCLUSIONS: T-CPR is an important strategy to increase early recognition and early CPR among pediatric OHCA.

Incidence, causes, and survival trends from cardiovascular-related sudden cardiac arrest in children and young adults 0 to 35 years of age: a 30-year review.

BACKGROUND: Sudden cardiac arrest is a leading cause of death in children and young adults. This study determined the incidence, cause, and outcomes of cardiovascular-related out-of-hospital cardiac arrest (OHCA) in individuals <35 years of age. METHODS AND RESULTS: A retrospective cohort of OHCA in children and young adults from 1980 through 2009 was identified from the King County (Washington) Division of Emergency Medical Services' Cardiac Arrest Database. Incidence was calculated from population census data and causes of arrest determined by review of autopsy reports and all available medical records. A total of 361 cases (26 cases 0-2 years of age, 30 cases 3-13 years of age, 60 cases 14-24 years of age, and 245 cases 25-35 years of age) of OHCA were treated by emergency medical services responders, for an overall incidence of 2.28 per 100 000 person-years (2.1 in those 0-2 years of age, 0.61 in those 3-13 years of age, 1.44 in those 14-24 years of age, and 4.40 in those 25-35 years of age). The most common causes of OHCA were congenital abnormalities in those 0 to 2 years of age (84.0%) and 3 to 13 years of age (21%), presumed primary arrhythmia in those 14 to 24 of age (23.5%), and coronary artery disease in those 25 to 35 years of age (42.9%). The overall survival rate was 26.9% (3.8% in those 0-2 years of age, 40.0% in those 3-13 years of age, 36.7% in those 14-24 years of age, and 27.8% in those 25-35 years of age). Survival increased throughout the study period from 13.0% in 1980 to 1989 to 40.2% in 2000 to 2009 (P<0.001). CONCLUSIONS: The incidence of OHCA in children and young adults is higher than previously reported, and a more specific understanding of the causes should guide future prevention programs. Survival trends support contemporary resuscitation protocols for OHCA in the young.

Impact of changes in resuscitation practice on survival and neurological outcome after out-of-hospital cardiac arrest resulting from nonshockable arrhythmias.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Nonshockable" rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain. METHODS AND RESULTS: We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival. CONCLUSION: Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

CPR with chest compression alone or with rescue breathing.

BACKGROUND: The role of rescue breathing in cardiopulmonary resuscitation (CPR) performed by a layperson is uncertain. We hypothesized that the dispatcher instructions to bystanders to provide chest compression alone would result in improved survival as compared with instructions to provide chest compression plus rescue breathing. METHODS: We conducted a multicenter, randomized trial of dispatcher instructions to bystanders for performing CPR. The patients were persons 18 years of age or older with out-of-hospital cardiac arrest for whom dispatchers initiated CPR instruction to bystanders. Patients were randomly assigned to receive chest compression alone or chest compression plus rescue breathing. The primary outcome was survival to hospital discharge. Secondary outcomes included a favorable neurologic outcome at discharge. RESULTS: Of the 1941 patients who met the inclusion criteria, 981 were randomly assigned to receive chest compression alone and 960 to receive chest compression plus rescue breathing. We observed no significant difference between the two groups in the proportion of patients who survived to hospital discharge (12.5% with chest compression alone and 11.0% with chest compression plus rescue breathing, P=0.31) or in the proportion who survived with a favorable neurologic outcome in the two sites that assessed this secondary outcome (14.4% and 11.5%, respectively; P=0.13). Prespecified subgroup analyses showed a trend toward a higher proportion of patients surviving to hospital discharge with chest compression alone as compared with chest compression plus rescue breathing for patients with a cardiac cause of arrest (15.5% vs. 12.3%, P=0.09) and for those with shockable rhythms (31.9% vs. 25.7%, P=0.09). CONCLUSIONS: Dispatcher instruction consisting of chest compression alone did not increase the survival rate overall, although there was a trend toward better outcomes in key clinical subgroups. The results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing. (Funded in part by the Laerdal Foundation for Acute Medicine and the Medic One Foundation; ClinicalTrials.gov number, NCT00219687.)

Dispatcher-assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest.

BACKGROUND: Dispatcher-assisted cardiopulmonary resuscitation (CPR) instructions can increase bystander CPR and thereby increase the rate of survival from cardiac arrest. The risk of bystander CPR for patients not in arrest is uncertain and has implications for how assertive dispatch is in instructing CPR. We determined the frequency of dispatcher-assisted CPR for patients not in arrest and the frequency and severity of injury related to chest compressions. METHODS AND RESULTS: The investigation was a prospective cohort study of adult patients not in cardiac arrest for whom dispatchers provided CPR instructions in King County, Washington, between June 1, 2004, and January 31, 2007. The study focused on those who received chest compressions. Information was collected through review of the audio and written dispatch report, written emergency medical services report, hospital record, and telephone survey. Of the 1700 patients for whom dispatcher CPR instructions were initiated, 55% (938 of 1700) were in arrest, 45% (762 of 1700) were not in arrest, and 18% (313 of 1700) were not in arrest and received bystander chest compressions. Of the 247 not in arrest who received chest compressions and had complete outcome ascertainment, 12% (29 of 247) experienced discomfort, and 2% (6 of 247) sustained injuries likely or possibly caused by bystander CPR. Only 2% (5 of 247) suffered a fracture, and no patients suffered visceral organ injury. CONCLUSIONS: In this prospective study, the frequency of serious injury related to dispatcher-assisted bystander CPR among nonarrest patients was low. When coupled with the established benefits of bystander CPR among those with arrest, these results support an assertive program of dispatcher-assisted CPR.

Merits of expanding the Utstein case definition for out of hospital cardiac arrest.

BACKGROUND: The Utstein population is defined by non-traumatic, bystander-witnessed out-of-hospital cardiac arrest (OHCA) presenting with ventricular fibrillation (VF). It is used to compare resuscitation performance across emergency medical services (EMS) systems. We hypothesized a system-specific survival correlation between the current Utstein population and other VF populations defined by unwitnessed VF OHCA and VF OHCA after EMS arrival (EMS-witnessed). Expanding performance metrics to this more comprehensive population would make the Utstein definition more representative of the actual community burden and response to VF OHCA. METHODS: We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated > = 100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used Pearson coefficient to assess whether there was a correlation of agency-specific survival outcomes between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA. RESULTS: A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between the current Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1-2, the Pearson correlation was 0.61. CONCLUSION: Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ∼50%, while still achieving a distinguishing metric of system-specific performance.

Out of hospital cardiac arrest: Past, present, and future.

Advances in resuscitation following out-of-hospital cardiac arrest (OHCA) provide an opportunity to improve public health. This review reflects on past developments, present status, and future possibilities using the science-education-implementation framework of the Utstein Formula and the clinical framework of the links in the chain of survival. With the discovery of CPR and defibrillation in the mid 20th century, resuscitation developed a scientific construct for progress. Systems of emergency community response provided operational efficiency to treat OHCA. Contemporary resuscitation involves integrated interventions in the chain of survival: early recognition, early CPR, early defibrillation, expert and timely advanced life support and hospital care, and multidimensional rehabilitation. Implementation of scientific advances is especially challenging given the unexpected nature of OHCA, the need for time-sensitive interventions, and the substantial collective of stakeholders involved in the chain of survival. Systematic measurement provides the foundation to evaluate performance and guide implementation initiatives. For many systems, telecommunicator CPR and high-performance CPR by emergency professionals are accessible, near-term programs to improve OHCA outcome. Smart technologies that activate, coordinate, and/or coach community "volunteers" to accelerate early CPR and defibrillation have conceptual promise, though robust implementation has been achieved by only a handful of systems. Longer-term strategies may leverage technology to develop a high-fidelity "life-detector" or engineer and disseminate a specialized consumer defibrillator designed to bridge care until arrival of professional response.

Association between functional status at hospital discharge and long-term survival after out-of-hospital-cardiac-arrest.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) causes brain injury. Functional status of survivors at hospital discharge is a core resuscitation measure, frequently using the Cerebral Performance Category (CPC) or modified Rankin Scale (mRS). Which scale better predicts long-term survival following OHCA is not known. METHODS: We evaluated long-term survival after hospital discharge in a retrospective cohort of persons resuscitated from OHCA in King County, WA from 2007 to 2015. Patients were independently assessed at discharge using both scales, leveraging the regional quality improvement registry, which records the 5-level CPC, and concurrent research studies involving the Resuscitation Outcomes Consortium, which used the 7-level mRS, taken from information in the hospital record. The risk of mortality associated with CPC and mRS categories was estimated using Kaplan-Meier survival analysis and Cox proportional hazards regression. RESULTS: Among 878 eligible patients discharged alive, there were 358 deaths during 9118.5 person-years of follow-up. Overall 1, 5 and 10-year survival was 84.4%, 68.5%, and 53.7% and varied according to CPC and mRS (p < 0.01 per Kaplan-Meier). Compared to CPC-1, hazard ratio (HR) increased incrementally for CPC-2 = 1.33 (1.03-1.73), CPC-3 = 1.90 (1.37-2.65), and CPC-4 = 8.25 (5.63-12.10). Compared to mRS = 0, HR for mRS-1 = 1.02 (0.66-1.58), mRS-2 = 1.52 (1.00-2.32), mRS-3 = 1.41 (0.92-2.14), mRS-4 = 2.00 (1.37-2.97), and mRS-5 = 4.90 (3.23-7.44). CONCLUSION: In OHCA survivors, CPC and mRS scales both predicted long-term survival. However mRS 0-1 and 2-3 groups did not have distinct prognoses, suggesting that a consolidated mRS score may simplify capture of relevant prognostic information for survival predictions.

Emergency communications with limited-English-proficiency populations.

OBJECTIVE: We investigated 9-1-1 telecommunicators' perceptions of communication difficulties with callers who have limited English proficiency (LEP) and the frequency and outcomes of specific communication behaviors. METHODS: A survey was administered to 150 telecommunicators from four 9-1-1 call centers of a metropolitan area in the Pacific Northwest to assess their experience working with LEP callers. In addition, 172 9-1-1 recordings (86 of which were labeled by telecommunicators as having a "language barrier") were abstracted for telecommunicators' communication behaviors and care delivery outcomes. All recordings were for patients who were in presumed cardiac arrest (patient unconscious and not breathing). Additionally, computer-assisted dispatch (CAD) reports were abstracted to assess dispatch practices with regard to timing of basic life support (BLS) and advanced life support (ALS) dispatch. RESULTS: One hundred twenty-three of the telecommunicators (82%) filled out the survey. The majority (70%) reported that they encounter LEP callers almost daily and most (78%) of them reported that communication difficulties affect the medical care these callers receive. Additionally, the telecommunicators reported that calls with LEP callers are often (36%) stressful. The number one strategy for communication with LEP callers reported by telecommunicators was the use of a telephone interpreter line known as the Language Line. However, the Language Line was utilized in only 13% of LEP calls abstracted for this study. The analysis of 9-1-1 recordings suggests that the LEP callers received more repetition, rephrasing, and slowing of speech than the non-LEP callers. Although there was no difference in time from onset of call to dispatching BLS, there was a significant difference in simultaneous dispatching of BLS and ALS between the LEP calls (20%) and non-LEP calls (38%, p < 0.05). CONCLUSION: Our study shows that 9-1-1 telecommunicators believe language barriers with LEP callers negatively impact communication and care outcomes. More research needs to be conducted on "best practices" for phone-based emergency communication with LEP callers. Additionally, LEP communities need to better understand the 9-1-1 system and how to effectively communicate during emergencies.

Seizure-like presentation in OHCA creates barriers to dispatch recognition of cardiac arrest.

PURPOSE: Early recognition of out-of-hospital cardiac arrest (OHCA) by 9-1-1 dispatchers is a critical first step along the resuscitation pathway. Barriers to recognition may lead to adverse outcomes among patients. This study aims to determine the impact of seizure-like activity among OHCA patients during 9-1-1 calls. METHODS: We evaluated a retrospective cohort study of all adult, non-traumatic OHCAs that occurred prior to emergency medical services (EMS) arrival on scene in a major metropolitan area from 2014-2018. Dispatch recordings were reviewed to determine if seizure-like activity was reported by the caller using key descriptor phrases such as "seizing," "shaking," or "convulsing." We compared patient demographics, arrest factors, and hospital outcomes using a regional OHCA quality improvement database. RESULTS: Among 3502 OHCAs meeting our inclusion criteria, 149 (4.3%) contained seizure-like activity. When compared to patients without seizure-like activity (3353; 95.7%), patients presenting with seizure-like activity were younger (54 vs. 66 years old; p < 0.05), had a witnessed arrest (88% vs 45%; p < 0.05), presented with an initial shockable rhythm (52% vs. 24%; p < 0.05), and survived to hospital discharge (44% vs. 16%; p < 0.05). The seizure-like activity group also had a longer median time to dispatcher identification of the cardiac arrest [130 s (72,193) vs 62 s (43,102); p < 0.05]. CONCLUSIONS: Reported seizure-like activity among patients in cardiac arrest poses a barrier to recognition of cardiac arrests by dispatchers leading to delays in resuscitation instructions.

The effect of paramedic experience on survival from cardiac arrest.

OBJECTIVE: We hypothesized that paramedics with more experience would be more successful at treating patients in ventricular fibrillation (VF) cardiac arrest than those with less experience. We conducted a study examining the relationship between the years of experience of paramedics and survival from out-of-hospital cardiac arrest. METHODS: This retrospective cohort study examined all witnessed, out-of-hospital VF cardiac arrests (n = 699) that occurred between January 1, 2002, and December 31, 2006. Logistic regression was used to determine the odds of survival and the 95% confidence intervals (95% CIs) relating to the number of years of experience that each of the treating paramedics had. RESULTS: We found that every additional year of experience of the medic in charge of implementing procedures such as intravenous line insertions, intubations, and provision of medications was associated with a 2% increase in the likelihood of survival of the patient (95% CI: 1.00-1.04). The number of years of experience of the paramedic who did not perform procedures but instead was in charge of treatment decisions was not significantly associated with survival (odds ratio [OR] 1.01, 95% CI: 0.99-1.03). When we combined both paramedics' years of experience, we saw a 1% increase in the odds of survival for every additional year of experience (95% CI: 1.00-1.03). CONCLUSIONS: This study suggests that the amount of experience of the paramedic who performed procedures on cardiac arrest patients was associated with increased rates of survival. However, we did not find an association between survival from VF and the number of years of experience of the paramedic who made treatment decisions.