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Resuscitation 85 (2014) 4952

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Resuscitation
j our nal homepage: www. el sevi er . com/ l ocat e/ r esusci t at i on
Clinical paper
Dispatch-assisted CPR: Where are the hold-ups during calls to
emergency dispatchers? A preliminary analysis of callerdispatcher
interactions during out-of-hospital cardiac arrest using a novel call
transcription technique

Gareth R. Clegg
a,b
, Richard M. Lyon
a,c,
, Scott James
a
, Holly P. Branigan
d
, Ellen G. Bard
e
,
Gerry J. Egan
f
a
Emergency Medicine Research Group, Edinburgh, United Kingdom
b
Queens Medical Research Institute, The University of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
c
Emergency Department, Royal Inrmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
d
Department of Psychology, University of Edinburgh, United Kingdom
e
Department of Linguistics and English Language, University of Edinburgh, United Kingdom
f
Scottish Ambulance Service, United Kingdom
a r t i c l e i n f o
Article history:
Received 3 June 2013
Received in revised form 5 August 2013
Accepted 21 August 2013
Keywords:
Out-of-hospital cardiac arrest
Resuscitation
Dispatch
Cardiopulmonary resuscitation
a b s t r a c t
Background: Survival from out-of-hospital cardiac arrest (OHCA) is dependent on the chain of survival.
Early recognition of cardiac arrest and provision of bystander cardiopulmonary resuscitation (CPR) are
key determinants of OHCA survival. Emergency medical dispatchers play a key role in cardiac arrest
recognitionand giving telephone CPRadvice. The interactionbetweencaller and dispatcher caninuence
the time to bystander CPR and quality of resuscitation. We sought to pilot the use of emergency call
transcription to audit and evaluate the holdups in performing dispatch-assisted CPR.
Methods: A retrospective case selection of 50 consecutive suspected OHCA was performed. Audio recor-
dings of calls were downloaded fromthe emergency medical dispatch centre computer database. All calls
were transcribed using proprietary software and voice dialogue was compared with the corresponding
stage on the Medical Priority Dispatch System(MPDS). Time to progress through each stage and number
of callerdispatcher interactions were calculated.
Results: Of the 50 downloaded calls, 47 were conrmed cases of OHCA. Call transcription was successfully
completed for all OHCA calls. Bystander CPR was performed in 39 (83%) of these. In the remaining cases,
the caller decided the patient was beyond help (n=7) or the caller said that they were physically unable
to perform CPR (n=1). MPDS stages varied substantially in time to completion. Stage 9 (determining if
the patient is breathing through airway instructions) took the longest time to complete (median=59s,
IQR 2282s). Stage 11 (giving CPR instructions) also took a relatively longer time to complete compared
to the other stages (median=46s, IQR 3775s). Stage 5 (establishing the patients age) took the shortest
time to complete (median=5.5s, IQR 39s).
Conclusion: Transcription of OHCA emergency calls and callerdispatcher interaction compared to MPDS
stage is feasible. Conrming whether a patient is breathing and completing CPR instructions required
the longest time and most interactions between caller and dispatcher. Use of call transcription has the
potential to identify key factors in callerdispatcher interaction that could improve time to CPR and
further research is warranted in this area.
2013 Elsevier Ireland Ltd. All rights reserved.

A Spanish translated version of the summary of this article appears as Appendix


in the nal online version at http://dx.doi.org/10.1016/j.resuscitation.2013.08.018.

Corresponding author at: Emergency Department, Royal Inrmary of Edinburgh,


Little France Crescent, Edinburgh EH16 4SA, United Kingdom.
E-mail address: richardlyon@doctors.org.uk (R.M. Lyon).
1. Introduction
Out-of-hospital cardiac arrest (OHCA) is a signicant cause of
mortality and serious neurological morbidity with over 275,000
OHCA occurring in Europe annually.
1
Survival-to-discharge rates
after OHCA continue to vary signicantly. Early bystander car-
diopulmonary resuscitation (CPR) has been shown to signicantly
improve survival from OHCA.
2,3
0300-9572/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.resuscitation.2013.08.018
50 G.R. Clegg et al. / Resuscitation 85 (2014) 4952
Emergency medical dispatchers can give instructions on per-
forming CPR. The introduction of a protocol for dispatch-assisted
CPR has been shown to improve rates of bystander CPR and out-
come from OHCA.
4
Emergency medical dispatch is the rst link in
the chain of survival and dispatch-assisted CPR plays a key role in
initiating early basic life support.
Rates of dispatch-assisted CPR are variable. Previous studies
have reported highly variable bystander CPR rates when the dis-
patcher offers CPR instructions. The most frequently cited reason
for not performing dispatch-assisted CPR is refusal to follow the
instructions givenby the dispatcher. The interactionbetweencaller
and dispatcher is a key to determining whether bystander CPR will
be performed. Identifying factors that would improve compliance
with dispatch-assisted CPR has the potential to increase bystander
CPR rates and potentially to save lives.
Call processing bydispatchers is important for dispatch-assisted
CPR.
5,6
Conrmation of cardiac arrest and establishing the geo-
graphical location of the incident both need to be undertaken
accurately and rapidly. The dispatcher needs to provide clear
instructions to the caller to performCPR. Any delay in commencing
CPR could have an adverse effect on patient outcome from OHCA.
Dispatch research has been designated a key area of research by
the European Resuscitation Council.
7
The interactions between caller and dispatcher inuence
bystander CPR. Dispatchcaller interaction can determine the
speed and accuracy of identication of cardiac arrest and can
facilitate timely initiation of bystander-CPR.
4
Audio recordings of
emergency calls have previously beenusedinanattempt toanalyse
callerdispatcher interaction as part of emergency dispatch quality
assurance. Many emergency dispatch systems use standard proto-
cols, such as Medical Priority Dispatch System(MPDS), to guide call
interrogation and advice. Audio transcription with mapping onto
the dispatch algorithm is a novel method of objectively analysing
callerdispatcher interaction.
We sought to pilot the use of audio call transcription as a novel
method of callerdispatcher audit and analyse callerdispatch
interactions during OHCAemergency calls toidentify factors affect-
ing the likelihood of bystanders performing dispatch-guided CPR.
2. Methods
2.1. Population
The regional Emergency Medical Dispatch Centre (EMDC),
based in Edinburgh, serves the population of south-east Scotland
(approximately 1.5 million population). Edinburgh EMDC handles
approximately 3000 calls per day. Emergency medical call handlers
undergo an8-week training programanddo not require any formal
qualications to undertake the role.
2.2. Cardiac arrest calls
All emergency calls taken by EMDC are recorded as digital audio
les. Audio les from 50 consecutive OHCA calls were selected
by MPDS classication from all OHCA calls between 2/3/2011 an
5/4/2011. Ethical permission for analyzing the calls was gained
from the University of Edinburgh. Calls were downloaded from
the EMDC system and stored on a secure computer system
within Edinburgh University. These recordings were transcribed
using ChannelTrans software (University of California, Berkeley)
to delineate the exact timing and content of the callerdispatcher
conversation throughout the call.
All emergency calls are handled by EMDC adhering closely to an
identical protocol. The dispatcher is directed through a pre-dened
series of questions to identify the nature of the call and priori-
tise an appropriate ambulance response. The triage systemused by
ScottishEMDCs is MPDS. The sequence of questions usedinthe case
of suspectedcardiac arrest is summarisedas a series of key stages in
Fig. 1. This sequence is rigidly adhered to by call-handlers. Calls are
systematically audited to check compliance with MPDS protocols.
Following transcription, timestamps were inserted to indicate
the move from one stage to the next. These timings formed a call
map for each of the 50 audio les and determination of the exact
amount of time spent moving through each stage of the call. The
number of turns was also determined for each stage. A turn is
dened as one persons speech between stretches of speech by the
other person. A turn might ask one or more questions or provide
instruction, information, or feedback.
3. Results
All of the audio les provided by the Scottish Ambulance Service
for the audit, all were of sufcient quality to allow for complete
transcription and further analysis of the caller/dispatcher interac-
tions. Version 12 MDPS was used without any changes for local
dialect or language. A single researcher transcribed all the calls
after minimal familiarisation with the ChannelTrans software. Of
the total 50 calls provided, three were excluded because the call
was not deemed to be an actual cardiac arrest by the investigators
(n=3). Of the remaining 47 calls, CPR was performed in 39 (83%).
Reasons for not performing CPR included the callers judgement
that the patient was beyond help (n=6) and the caller reporting
that they were physically unable to performCPR (n=1). In one case
CPR was already on going when the emergency call was made and
this case was excluded. 46 (98%) calls were placed by individuals
known to the patient and only one call was placed by a passer-by
who was a stranger to the patient.
The timestamp data and number of turns at each stage of the
call were recorded and plotted. Turns versus time were plotted
for each of the ten primary MPDS stages shown in Fig. 1. There
was a positive correlation between the time taken to complete
stage 9 (determining if the patient is breathing through airway
instructions) and the number of turns in the callercall handler
interaction (r
2
=0.871). There was no relationship between time
taken and number of turns on the remaining stages.
The time spent on each individual MPDS stage is the shown in
Fig. 2. The plot shows the progress of the call through the MPDS
protocol. Several stages took a relatively long time to complete.
Stage 9 (determining if the patient is breathing by moving patient
to oor and airway instructions) took the longest (median=59s,
IQR 2282s). Stage 11 (giving CPR instructions) was also longer
relative to the other stages (median=46s, IQR 3775s). Stage 5
(establishing the patients age) took the shortest time to complete
(median=5.5s, IQR 39s).
The number of turns plotted against MPDS stage is shown in
Fig. 3. Stage 9 (determining if the patient is breathing by moving
patient to the oor and airway instructions) took the most number
of turns to complete and had the widest range of turns (median=6,
IQR 311). Stage 7 (asking if the patient is breathing) also had a
wide range of turns (median=2, IQR 15).
Both analyses by time and number of turns identied stages 7
(asking if patient is breathing) and 9 (determining if the patient
is breathing by moving patient to oor and airway instructions)
as steps on the MPDS protocol that could be targeted to improve
time to bystander CPR. In our sample the time spent transitioning
through stage 9 (airway instructions and placing patient at on
ground) did not signicantly affect the time to starting CPR, but
there was a signicant relationship between the number of turns
on stage 9 and the number of turns before CPR instructions were
given (p=0.0005 CI 95%).
The time elements for each stage are shown in cumulative in
Fig. 4. The cumulative mean time to identication of cardiac arrest
G.R. Clegg et al. / Resuscitation 85 (2014) 4952 51
Fig. 1. Summary of the key stages in the MPDS call protocol for out-of-hospital cardiac arrest.
was 03:39 (range 00:3309:40) and rst chest compression 04:45
(range 00:2410:47).
4. Discussion
OHCA call download, transcription and analysis are possible
with a high degree of data accuracy. Comparison of the call tran-
script to ambulance dispatch protocols such as MPDS can identify
key stages in the call that delay bystander CPR. Accurately identify-
ing whether a patient is breathing and giving CPR instructions take
the longest time and most turns, possibly reecting the difculties
encountered in getting the bystander to complete the requested
tasks. These stages could be specically targeted during dispatcher
training and could be the focus of future dispatch research.
Fig. 2. Stage vs. time for all calls (n=47).
The number of turns taken to complete each MPDS stage may
give an indication of the clarity of the dispatch instructions. Stages
witha highnumber of turns may indicate areas where communica-
tion is poor. This will of course be affected by factors unique to the
callers and call-handlers themselves (e.g. hearing acuity, level of
cognitive function, etc.), but where difculties occur in a majority
of calls, or where the range of timings and turn taking is large, the
distribution of stage durations may indicate factors in the EMDC
system itself which may be improved.
Undertaking dispatch analysis by this means ensures account-
ability. Thecall takingprocess is not routinelyauditedingreat detail
but is a crucially important step in the chain of survival. Pre-ROSC
elements in the chain of survival are critically time-dependent and
their duration is likely to be of disproportionate importance when
compared with other subsequent links. Dispatch analysis of this
time is manpower intensive and further research is warranted on
using technology to automate some of this process.
Fig. 3. Stage vs. turns for all calls (n=47).
52 G.R. Clegg et al. / Resuscitation 85 (2014) 4952
Fig. 4. Cumula times to CPR by stage for 47 calls.
Previous studies have demonstratedanimprovedoutcome from
OHCAwhenthe initial emergency call is handledby anexperienced
dispatcher.
8
This is consistent with our results as experienced dis-
patchers may be able to negotiate the problematic stages, such as
determining whether the patient is breathing, more rapidly. We
noted that relatives of OHCA victims placed a high proportion of
calls, and may be prone to a higher degree of emotional stress dur-
ing the emergency call thanunrelated bystanders. It is possible that
experienced or talented dispatchers may succeed in dealing with
such distress more effectively and ensure that bystander CPR is
performed in timely fashion.
This study has several limitations. The number of calls ana-
lysed was relatively small and may not be representative of the
wider OHCApopulation. However, call transcriptionwas accurately
completedinall calls, afrming the usefulness of this researchtech-
nique for dispatch analysis.
Further investigation is warranted in this eld. Transcribing and
analysing a larger number of OHCA calls would conrm call stages
that require improvement. Comparing calls where an accurate con-
rmation of cardiac arrest is achieved and dispatch-assisted CPR
started promptly to calls where diagnosis and CPR are delayed may
allow dispatch factors to be identied for targeted training and
improvement. Identifying factors in the language, tone and manner
the dispatcher uses may be important. Further analysis of discourse
between caller and dispatcher may identify ways to enhance and
streamline communication to aid diagnosis of OHCA and decrease
time to CPR.
5. Conclusion
Transcription of OHCA emergency calls and callerdispatcher
interactionby MPDS stage is feasible. Conrming whether a patient
is breathing and completing CPR instructions required the longest
time and most interactions between caller and dispatcher. Use
of call transcription has the potential to identify key factors in
callerdispatcher interaction that could improve time to CPR and
further research is warranted in this area.
Funding
This project was supported by the University of Edinburgh.
Conict of interest statement
None to declare.
References
1. Atwood C, Eisenberg MS, Herlitz J, et al. Incidence of EMS-treated out-of-hospital
cardiac arrest in Europe. Resuscitation 2005;67:7580.
2. Bardy GH. A critics assessment of our approach to cardiac arrest. N Engl J Med
2011;364:3745.
3. Sasson C, Rogers MAM, Dahl J, et al. Predictors of survival from out-of-hospital
cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Out-
comes 2010;3:6381.
4. Nurmi J, Pettil V, Biber B, et al. Effect of protocol compliance to cardiac
arrest identication by emergency medical dispatchers. Resuscitation 2006;70:
4639.
5. Castrn M, Bohm K, Kvam AM, et al. Reporting of data from out-of-hospital
cardiac arrest has to involve emergency medical dispatching taking the rec-
ommendations on reporting OHCA the Utstein style a step further. Resuscitation
2011;82:1496500.
6. Svensson L, Bohm K, Castren M, et al. Compression-only CPR or standard CPR in
out-of-hospital cardiac arrest. N Engl J Med 2010;363:43442.
7. Nolan JP, Soar J. Dispatcher-assisted bystander CPR: a KISS for a kiss. Lancet
2010;376:15224.
8. Kuisma M, Boyd J, Vyrynen T, et al. Emergency call processing and
survival from out-of-hospital ventricular brillation. Resuscitation 2005;67:
8993.

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