Bundled Telephone CPR Program Increases Survival After Out-of-Hospital Cardiac Arrest

Deborah Brauser

May 06, 2016

PHOENIX, AZ — A guideline-based telephone CPR (TCPR) program, including specific protocols, telecommunicator training, and feedback meetings, can significantly improve how quickly CPR is administered after a bystander-witnessed out-of-hospital (OOH) cardiac arrest and can increase patient survival, suggests new research[1].

The study of more than 2000 OOH cardiac arrests showed that the time to first chest compression was reduced from a mean of 256 seconds before the adoption of the TCPR protocols (phase 1) to 212 seconds afterward (phase 2, P<0.001).

Survival to hospital discharge for all rhythms combined, as well as for shockable initial rhythms only, was greater in phase 2 vs phase 1 (P=0.02 for both comparisons). In addition, "favorable functional outcome," meaning good neurologic function at hospital discharge, was significantly improved (P=0.01).

The findings were published online May 4, 2016 in JAMA Cardiology.

The investigators, led by Dr Bentley J Bobrow (Arizona Department of Health Services, Phoenix), note that the project "was associated with significant improvements in several important aspects of resuscitation care . . . and, more important, a 31.8% relative increase in [overall] survival."

Coinvestigator Dr Daniel W Spaite (Arizona Department of Health Services) told heartwire from Medscape that he was also impressed with the 40% relative increase in neurologically intact survival. "This was remarkable given the fact that the program included many agencies, fire departments, hospitals, and communities.

"That's why I think this will be found to be a seminal paper. In a setting that wasn't a real tight research environment, we found dramatic results from a very simple intervention with almost no incremental costs," said Spaite.

However, in an accompanying editorial[2], Drs James T Niemann and Roger J Lewis (Harbor-University of California, Los Angeles Medical Center, Torrance) note that because the study didn't categorize outcomes by race or ethnicity groups, where recent reports have shown disparities for bystander CPR[3], the findings may not be so generalizable to other settings.

Dr Clyde W Yancy (Northwestern University, Chicago, IL) writes in an accompanying editor's note[4] that he agrees with Niemann and Lewis that there is a dire situation when it comes to at-risk communities, and he issued a call for the continued pursuit of research and interventions for this high-risk population.

Still, because of the significant improvements shown with the deployment of the Arizona TCPR program overall, he said Bobrow et al's study "is of considerable importance to the cardiovascular community and has notable public-health implications."

Past Results "Mixed"

"Typically, if you look across the country, most systems have only about 30% of people doing bystander CPR," reported Spaite. He noted that past research has shown that TCPR can increase the rates of layperson CPR, but "results have been mixed as to whether it actually improves survival significantly."

For this analysis, the investigators assessed 2334 OOH cardiac arrests (64% men; mean age 63 years) that occurred within metropolitan Phoenix from October 2010 through September 2013. Of these, 798 occurred before the TCPR bundled program was put into place and 1536 were after implementation.

All patient records were taken from the Save Hearts in Arizona Registry and Education (SHARE) database and included only patients who were treated by emergency medical services (EMS) after a non–EMS-witnessed cardiac arrest.

Participants in the TCPR bundled-care program included two 911 medical dispatch centers and 250 telecommunicators, 30 EMS agencies, and 22 receiving hospitals. The program "was based on the latest American Heart Association guidelines for TCPR," report the investigators, and included specific protocols, training modules, call recordings, and feedback.

The protocols specified using compression-only CPR when the arrest was presumed to be cardiac-related and "compression with rescue breaths" for other types of arrests. The telecommunicators were told to immediately ask the following two questions as soon as a call came in:

  • Is the patient conscious?

  • Is the patient breathing normally?

Instructions were to be given only if the answer to both was "no." After explaining what to do, the dispatchers told the caller to put down the phone and count out loud the compressions from one to 10. Then they were to come back to the call for any adjustments before returning to the compressions and out-loud counting until EMS arrived. This counting, heard on the audio recording, was part of the later review process to see whether dispatchers could have given clearer instructions.

First Large-scale TCPR Study

Use of TCPR increased from 43.5% during the first phase to 52.8% in the second phase (P<0.001).

For patients with a shockable initial rhythm, the survival rate was 24.7% during phase 1 vs 35.0% in phase 2 (adjusted odds ratio [OR] 1.70, 95% CI 1.1–2.7). The all-rhythm-survival rate was 9% vs 12%, respectively (OR 1.47, 95% CI 1.1-2.0).

In addition, favorable function outcome for all rhythms increased from 5.6% to 8.3% (adjusted OR 1.68, 95% CI 1.1–2.5), and increased from 17.1% to 28.8% for those with shockable rhythms (OR 2.13, 95% CI 1.3–3.6).

"To our knowledge, this investigation is the first large-scale study of a TCPR program based on the latest guideline recommendations and implemented in multiple EMS systems," write the researchers.

Spaite noted that the intervention was created for a system that already had a TCPR program in place, just as many other US communities have but aren't using effectively. "We found that it doesn't really work if you don't do the entire bundle of services together," he said.

"Ten years ago in Arizona, we had about a 2% survival rate after cardiac arrest. But we now have over 3000 survivors. Dispatchers went from worrying about cardiac-arrest calls to saying, 'Great, we can save this person' and realizing they're one of the most important links in the chain."

"Dramatically Different" Outcomes

In their editorial, Niemann and Lewis note that the study's outcomes "were dramatically different from recent studies," which may be due to the well-structured protocols and "rigorous training" that the program used.

"Emphasis was placed on chest compression only for cardiac arrests of presumed cardiac etiology, with ventilation instructed only for events not believed to be of primary cardiac origin," they write.

Spaite noted that the outcomes were also probably higher because of the study's real-world setting.

As to the editorialists' earlier criticism about not stratifying for race or ethnicity and questioning the study's generalizability, he said that the investigators are now submitting multiple grant requests to the National Institutes of Health "to truly quantify our experience." In addition, they'll be using geomapping in a follow-up study to further separate out their patient population.

Spaite added that all study data and program information are available on the AZSHARE.gov website.

Bobrow and Spaite reported university support from Medtronic Philanthropy but no other disclosures. The coauthors report no relevant financial relationships, as do the editorialists and Yancy.

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