- Email: [email protected]
Emergency medical dispatch – More than merely sending the ambulance!
Resuscitation 82 (2011) 1473–1474
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Emergency medical dispatch – More than merely sending the ambulance!
The crucial inter-relationship between time to interventions and survival following cardiac arrest is well established. Time to act following onset of chest pain, time to commencement of cardiopulmonary resuscitation (CPR), time to defibrillation for shockable rhythms, time to advanced life support and timing of post resuscitation care are all key system factors that contribute to improve survival. The effectiveness of many of these interventions relies on how quickly the emergency medical services (EMS) are activated in response to confirmed or suspected cardiac arrest in the community. The need for early activation of the EMS is well identified within the basic life support algorithm in many national resuscitation councils worldwide and by ILCOR.1–3 Activating the EMS – or more pragmatically calling the ambulance – would seem on the surface a relatively simple process. However, emergency medical dispatch brings together several complex processes and issues including accurate identification of cardiac arrest, communications, critical telephone advice and EMS resource allocation.4 The use of structured call taking or other protocol based dispatch systems are used within many EMS systems worldwide to provide a consistent approach to respond to community-based medical emergencies including cardiac arrest. Failing to maximize such processes will result in a suboptimal response and potentially patient survival – or does it! In this issue of Resuscitation there are three papers that address some of the fundamental issues surrounding emergency medical dispatch. A significant challenge for emergency medical dispatchers is determining events that are, or have a very high probability of being, cardiac arrests. Vaillancourt et al. have undertaken a systematic review of the published literature to determine what symptoms reported to emergency medical dispatchers may be useful in improving the accuracy of identifying cardiac arrest.5 Their review demonstrates that the sensitivity of unconsciousness and nil or abnormal breathing status in identifying cardiac arrest varies widely across studies (38–97%), most likely reflecting the heterogeneity of studies included. As such, the reported presence of such symptoms remains reliable in identifying cardiac arrest. Further, the review also identified that the presence of abnormal breathing and/or seizure activity further complicates the accurate identification of cardiac arrest. The inability to identify reliably cardiac arrest at the point of dispatch will continue to impede the appropriate allocation of EMS resources to cardiac arrests. This may be improved by further widening the dispatch criteria; however, this will inevitably lead to an increase in the false positive rate and further pressure of EMS response. Bohm et al. sought to assess the effectiveness of telephone CPR advice.6 In essence, does providing telephone CPR advice improve
0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2011.10.004
the likelihood of survival following cardiac arrest. In their systematic review the authors identified only five descriptive studies and no randomised controlled trials. The review demonstrated the paucity of evidence for this intervention but recommended reasonably continuation of this practice. One of the clear findings from the consensus on CPR Science and Treatment Recommendations published in 2010 was the lack of evidence underpinning many of the current resuscitation interventions including in the area of emergency medical dispatch.1 This has been exemplified in the two systematic reviews published in this journal. Addressing this evidence gap will require international collaboration across numerous agencies involved in the dispatch of EMS. Specifically, there is a need to build the evidence not only to determine the efficacy and effectiveness of the various components of emergency medical dispatch, but also the various call taking and dispatch decision support systems. However, consistency in terminology, methods and processes for evaluation and research will be paramount in moving this research agenda forward. Castren et al. have outlined a starting point for this endeavor by providing a framework for the development of uniform terminology, definitions and data collection, along an Utstein style process, for emergency medical dispatch.7 The Utstein style recommendations and templates in other domains have helped considerably in producing consistent reporting of resuscitation research and outcomes.8 To this end, having a uniform framework, as suggested by Castren, makes good sense. However the authors will need to be cognizant that further international dialogue will need to take place to achieve international acceptance and utility for a uniform reporting process in emergency medical dispatch. This has certainly been the collective experience in the initial development and revision of current Utstein style reporting recommendations and templates.9 So what is our current evidence base for emergency medical dispatch? Reported signs indicating cardiac arrest, predominantly unconsciousness and absent or not normal breathing, are not accurate. The development of more sensitive indicators of cardiac arrest will be crucial to enable appropriate allocation of EMS resources. Telephone CPR instructions provided by emergency medical dispatchers have not been shown to improve survival following cardiac arrest, but the concept seems sound and further evidence is required. The effectiveness of any specific structured call taking or other protocol-based dispatch system in improving cardiac arrest outcomes has yet to be demonstrated. The development of a serious research agenda in emergency medical dispatch is essential if these and other related questions are to be addressed. The three related papers published in this journal are important, useful and timely in this regard.
1474
Editorial / Resuscitation 82 (2011) 1473–1474
Conflicts of interest None. References 1. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(Suppl. 1):e1–25. 2. Deakin CD, Nolan JP, Soar J, et al. European resuscitation council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation 2010;81:1305–52. 3. Leman P, Jacobs I. What is new in the Australasian adult resuscitation guidelines for 2010? Emerg Med Australas 2011;23:237–9. 4. Ornato JP. Science of emergency medical dispatch. Circulation 2009;119:2023–5. 5. Vaillancourt et al. In out-of-hospital cardiac arrest patients, does the description of any specific symptoms to the emergency medical dispatcher improve the accuracy of the diagnosis of cardiac arrest: a systematic review of the literature. RESUS-D11-00104R1. 6. Bohm et al. In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no
instructions improve outcome: a systematic review of the literature. RESUS-D11-00110R2. 7. Castren et al. Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching – taking the recommendations on reporting OHCA the Utstein style a step further. RESUS-D-11-00345R1. 8. Fredriksson M, Herlitz J, Nichol G. Variation in outcome in studies of out-ofhospital cardiac arrest: a review of studies conforming to the Utstein guidelines. Am J Emerg Med 2003;21:276–81. 9. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63:233–49.
Ian G. Jacobs University of Western Australia, Nedlands, Western Australia, Australia E-mail address: [email protected]
Contents lists available at SciVerse ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Emergency medical dispatch – More than merely sending the ambulance!
The crucial inter-relationship between time to interventions and survival following cardiac arrest is well established. Time to act following onset of chest pain, time to commencement of cardiopulmonary resuscitation (CPR), time to defibrillation for shockable rhythms, time to advanced life support and timing of post resuscitation care are all key system factors that contribute to improve survival. The effectiveness of many of these interventions relies on how quickly the emergency medical services (EMS) are activated in response to confirmed or suspected cardiac arrest in the community. The need for early activation of the EMS is well identified within the basic life support algorithm in many national resuscitation councils worldwide and by ILCOR.1–3 Activating the EMS – or more pragmatically calling the ambulance – would seem on the surface a relatively simple process. However, emergency medical dispatch brings together several complex processes and issues including accurate identification of cardiac arrest, communications, critical telephone advice and EMS resource allocation.4 The use of structured call taking or other protocol based dispatch systems are used within many EMS systems worldwide to provide a consistent approach to respond to community-based medical emergencies including cardiac arrest. Failing to maximize such processes will result in a suboptimal response and potentially patient survival – or does it! In this issue of Resuscitation there are three papers that address some of the fundamental issues surrounding emergency medical dispatch. A significant challenge for emergency medical dispatchers is determining events that are, or have a very high probability of being, cardiac arrests. Vaillancourt et al. have undertaken a systematic review of the published literature to determine what symptoms reported to emergency medical dispatchers may be useful in improving the accuracy of identifying cardiac arrest.5 Their review demonstrates that the sensitivity of unconsciousness and nil or abnormal breathing status in identifying cardiac arrest varies widely across studies (38–97%), most likely reflecting the heterogeneity of studies included. As such, the reported presence of such symptoms remains reliable in identifying cardiac arrest. Further, the review also identified that the presence of abnormal breathing and/or seizure activity further complicates the accurate identification of cardiac arrest. The inability to identify reliably cardiac arrest at the point of dispatch will continue to impede the appropriate allocation of EMS resources to cardiac arrests. This may be improved by further widening the dispatch criteria; however, this will inevitably lead to an increase in the false positive rate and further pressure of EMS response. Bohm et al. sought to assess the effectiveness of telephone CPR advice.6 In essence, does providing telephone CPR advice improve
0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2011.10.004
the likelihood of survival following cardiac arrest. In their systematic review the authors identified only five descriptive studies and no randomised controlled trials. The review demonstrated the paucity of evidence for this intervention but recommended reasonably continuation of this practice. One of the clear findings from the consensus on CPR Science and Treatment Recommendations published in 2010 was the lack of evidence underpinning many of the current resuscitation interventions including in the area of emergency medical dispatch.1 This has been exemplified in the two systematic reviews published in this journal. Addressing this evidence gap will require international collaboration across numerous agencies involved in the dispatch of EMS. Specifically, there is a need to build the evidence not only to determine the efficacy and effectiveness of the various components of emergency medical dispatch, but also the various call taking and dispatch decision support systems. However, consistency in terminology, methods and processes for evaluation and research will be paramount in moving this research agenda forward. Castren et al. have outlined a starting point for this endeavor by providing a framework for the development of uniform terminology, definitions and data collection, along an Utstein style process, for emergency medical dispatch.7 The Utstein style recommendations and templates in other domains have helped considerably in producing consistent reporting of resuscitation research and outcomes.8 To this end, having a uniform framework, as suggested by Castren, makes good sense. However the authors will need to be cognizant that further international dialogue will need to take place to achieve international acceptance and utility for a uniform reporting process in emergency medical dispatch. This has certainly been the collective experience in the initial development and revision of current Utstein style reporting recommendations and templates.9 So what is our current evidence base for emergency medical dispatch? Reported signs indicating cardiac arrest, predominantly unconsciousness and absent or not normal breathing, are not accurate. The development of more sensitive indicators of cardiac arrest will be crucial to enable appropriate allocation of EMS resources. Telephone CPR instructions provided by emergency medical dispatchers have not been shown to improve survival following cardiac arrest, but the concept seems sound and further evidence is required. The effectiveness of any specific structured call taking or other protocol-based dispatch system in improving cardiac arrest outcomes has yet to be demonstrated. The development of a serious research agenda in emergency medical dispatch is essential if these and other related questions are to be addressed. The three related papers published in this journal are important, useful and timely in this regard.
1474
Editorial / Resuscitation 82 (2011) 1473–1474
Conflicts of interest None. References 1. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(Suppl. 1):e1–25. 2. Deakin CD, Nolan JP, Soar J, et al. European resuscitation council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation 2010;81:1305–52. 3. Leman P, Jacobs I. What is new in the Australasian adult resuscitation guidelines for 2010? Emerg Med Australas 2011;23:237–9. 4. Ornato JP. Science of emergency medical dispatch. Circulation 2009;119:2023–5. 5. Vaillancourt et al. In out-of-hospital cardiac arrest patients, does the description of any specific symptoms to the emergency medical dispatcher improve the accuracy of the diagnosis of cardiac arrest: a systematic review of the literature. RESUS-D11-00104R1. 6. Bohm et al. In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no
instructions improve outcome: a systematic review of the literature. RESUS-D11-00110R2. 7. Castren et al. Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching – taking the recommendations on reporting OHCA the Utstein style a step further. RESUS-D-11-00345R1. 8. Fredriksson M, Herlitz J, Nichol G. Variation in outcome in studies of out-ofhospital cardiac arrest: a review of studies conforming to the Utstein guidelines. Am J Emerg Med 2003;21:276–81. 9. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63:233–49.
Ian G. Jacobs University of Western Australia, Nedlands, Western Australia, Australia E-mail address: [email protected]