CPR LifeLinks 911 and EMS united to save more lives

CPR LifeLinks is a national initiative that encourages local collaboration between 911 and EMS to improve out-of-hospital cardiac arrest survival rates by improving care in the first links in the “chain of survival,” early 911 access/intervention and early (and effective) CPR. The CPR LifeLinks Implementation Toolkit Find resources and a practical roadmap for how: Any 911 agency can put telecommunicator CPR protocols and training into place. Agencies providing EMS can implement high performance CPR.

Learn strategies and explore case studies for how 911 and EMS can collaborate, working together to strengthen the chain of survival. DRAFT VERSION 1.0 | 2018 RELEASED FOR PUBLIC FEEDBACK

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Table of Contents 2

INTRODUCTION ................................................................................................................. 3 3

PART 1: TELECOMMUNICATOR CPR (T-CPR) ........................................................................... 7 4 Section 1: Overview..................................................................................................................... 7 5 Section 2: The Commitment to Act: Challenges and Perspectives ............................................ 9 6 Section 3: AHA T-CPR Program and Performance Recommendations .................................... 12 7 Section 4: Protocols .................................................................................................................. 14 8 Section 5: Telecommunicator Training ..................................................................................... 17 9 Section 6: Achieving a T-CPR Culture of Excellence ................................................................. 34 10

Appendices 11 Appendix 1: The Physiology of Out-of-Hospital Cardiac Arrest (OHCA) ................................... 39 12 Appendix 2: When to Do Conventional CPR (CPR with Compressions Rescue Breathing) ....... 40 13 Appendix 3: Critical Incident Stress Management ................................................................... 41 14 Appendix 4: History of T-CPR ................................................................................................... 42 15 Appendix 5: T-CPR Resources .................................................................................................... 43 16

PART 2: HIGH PERFORMANCE CPR (HP-CPR) ........................................................................ 44 17

Section 1: Overview .................................................................................................................. 44 18 Section 2: The Commitment to Act: Challenges and Perspectives .......................................... 45 19 Section 3: Performance Recommendations ............................................................................. 45 20 Section 4: Common CPR Quality Issues ............................................................................... 49 21 Section 5: Training ..................................................................................................................... 53 22 Section 6: Achieving an HP-CPR Culture of Excellence ............................................................. 66 23

Appendices 24 Appendix 1: Barriers to HP-CPR Implementation ..................................................................... 70 25 Appendix 2: Chest Compressions .............................................................................................. 76 26 Appendix 3: Ventilation ............................................................................................................ 76 27 Appendix 4: Minimally Interrupted Cardiac Resuscitation (MICR) .......................................... 77 28 Appendix 5: Defibrillation ......................................................................................................... 77 29 Appendix 6: Termination of Resuscitation ................................................................................ 78 30 Appendix 7: Transition to Automated Chest Compression Devices ......................................... 78 31 Appendix 8: HP-CPR Resource................................................................................................... 79 32

PART 3: ABOUT THE INITIATIVE—PARTICIPANTS IN THE EXPERT PANELS AND THE PROCESS 33 FOR CREATING THE TOOLKIT ................................................................................................ 84 34

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INTRODUCTION 2

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CPR LifeLinks: 911 and EMS United to Save More Lives 4 5

Imagine this scene: Margaret, a 47-year-old mother, has just finished serving breakfast to her 6 daughter, Jennifer, a senior in high school. Jennifer suddenly hears a crashing sound in the 7 kitchen. She finds her mom is lying on the floor, not moving. She kneels next to her and yells, 8 “Mom, are you OK?” There is no response. Jennifer frantically dials 911. 9 10 Jennifer sobs as the public safety telecommunicator, Andy, confirms the address and phone 11 number and asks the nature of the emergency. “My mother just collapsed in the kitchen and I 12 can’t get her to talk to me,” she tells him. Although he only gets calls for cardiac arrest a couple 13 of times a year, Andy is trained to assume that every call is a cardiac arrest until proven 14 otherwise. 15 16 “Is your Mom breathing normally?” he asks. “I can’t tell,” Jennifer says, “she’s gasping.” Andy 17 can hear noises faintly in the background and from his training quickly recognizes they are 18 agonal breaths, a sign that the arrest occurred very recently. “I’m dispatching an ambulance,” 19 he says. You need to do chest compressions until they get there. I’m going to help you. Let’s 20 start.” 21 22 For the next five minutes, Andy coaches Jennifer to do effective chest compression-only CPR. 23 She’s alone, and he knows he needs to support her efforts to do continuous compressions at the 24 proper rate and depth. “We can do this together,” he assures her in a calm, assertive voice. 25 “Just keep going. You can do it.” 26 27 Firefighters arrive first. They assume pre-assigned positions around Margaret and take over 28 compressions from Jennifer, with minimal interruption. Andy tells her he is going to hang up 29 now, and that her Mom is in good hands – indeed, one of the firefighters had trained him in 30 compression-only CPR a few months before, a key component of telecommunicator CPR. 31 32 The firefighters have been trained in high-performance CPR and know how critical this 33 intervention is for survival. Paramedics arrive and work seamlessly. After several shock 34 attempts and rounds of CPR, Margaret regains a pulse and starts to breath on her own. The 35 rescuers perform a 12-lead ECG, stabilize her, and transport her to the nearest designated 36 cardiac center. 37 38 A few months later, Margaret, Jennifer and several family members come together with Andy 39 and the firefighters and paramedics at the 911 center, a gathering arranged by leaders to 40 celebrate the life saved. Although they are part of the same team, Andy doesn’t see the 41 firefighters and paramedics often, but these opportunities to celebrate the lives they save 42 empower them all in their work. 43 44 # # # 45

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Out-of-hospital cardiac arrest (OHCA), the sudden failure of all electrical and mechanical activity 1 in the heart, is a leading cause of death in the United States and across the world. It is our most 2 time-sensitive medical emergency, and early CPR is vital. In its absence, the patient is, in all 3 likelihood, dead when professional rescuers arrive. Indeed, the chance a patient lives falls by 4 about 7-10% per minute without CPR.i ii 5 6 While many factors contribute to survival, years of study show the profound impact of two 7 interventions: Telecommunicator Cardiopulmonary Resuscitation (T-CPR) and High-Performance 8 CPR (HP-CPR) by Emergency Medical Service (EMS) responders. 9 10 TCPR, where bystanders perform pre-arrival chest compressions as directed by 11 telecommunicators, generates essential blood flow to the heart and brain and is associated with 12 better long-term outcomes. HP-CPR, in turn, ensures that trained responders maximize this 13 blood flow so that electrical shocks and airway management can secure a successful outcome. In 14 this way, these links in the chain are really a single, continuous effort to restore circulation as 15 soon as possible. We know that much of the OHCA battle is won or lost in the initial minutes at 16 the scene of cardiac arrest. 17

18 In 2015, the Institute of Medicine recommended that EMS systems take steps to enhance T-CPR 19 and HP-CPR to improve patient outcomes in their communities. To help achieve this goal, the 20 National Highway Traffic Safety Administration created CPR LifeLinks, a national initiative 21 encouraging local 911 and EMS systems to collaborate on improving care in the first links in the 22 “chain of survival:” early T-CPR and high performance CPR. 23 24 As the case study from Bend, Oregon shows (editor’s note: to be inserted following public 25 comment phase), collaboration saves lives. 26 27 The CPR LifeLinks Implementation Toolkit provides resources and a practical roadmap for 28 implementing telecommunicator CPR and high performance CPR. The process for developing 29 the Toolkit and the people behind it are summarized in PART 3 of this document. 30

31 Imagine a Stadium Full of Survivors 32 There are an estimated 250,000 cases of OHCA in the U.S. every year, and average survival rates 33 are low – about 10% overall and about 30% when first responders find patients in ventricular 34 fibrillation (VF), the shockable rhythm usually associated with arrest onset. 35 36 If survival rates were improved from 10% to even 12.5% nationwide, more than 60,000 lives 37 could be saved over the course of a decade, enough to fill a sports stadium! And think of the 38 many thousands of family members and friends given additional time with their loved ones. 39 40 How Does Your Community Measure Up? 41 Survival rates vary five-fold from one city to another. Unfortunately, where you live affects if 42 you live. Why the tremendous disparity? Do you know your own community’s OHCA survival 43 rate? Is your EMS system part of a standardized OHCA registry that details each event and 44 provides important benchmarking and research opportunities? 45 46 47

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1 Figure 1: (to be inserted following public comment phase). The Chain of Survival represents 2 an integrated system of OHCA care. A bystander’s prompt 9-1-1 call enables early T-CPR (the 3 second link), which increases the chance that HP CPR (the third link) restores circulation. 4

5 Implementation 6 While T-CPR and HP-CPR are relatively simple interventions, implementing them can be 7 challenging. It is essential to identify barriers that stand in the way of providing these 8 treatments. Some are common and entrenched in agency culture and operations. Planning and 9 commitment to change are required to dissolve them. We address these challenges in PART 1, 10 Section 2 and PART 2, Section 2 of this document. 11

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Measurement is essential to optimize care and makes a huge difference in saving lives. Systems 14 may face challenges implementing all aspects of these programs, but they should take and build 15 on small steps in their immediate grasp. First steps – measuring the rate at which 16 telecommunicators recognize OHCA in a three-month period, for example – bring mere 17 concepts to life and foster the motivation to do more. Agencies sincere in their efforts to 18 improve can practice most if not all the recommendations here and achieve a “culture of 19 excellence.” 20

21 T-CPR & HP-CPR Cultures of Excellence: Earning It Every Day 22 OHCA tests 911 Centers and EMS care more than any other time-sensitive medical condition and 23 is an accepted benchmark for a system’s overall performance. Agencies that seek a culture of 24 excellence will save lives and realize additional health benefits as the attention to training and 25 performance translate to better care across the spectrum of acute medical and traumatic 26 conditions. 27 28 A culture of excellence requires a shared organizational vision. It incorporates a team effort 29 where individuals appreciate their roles and confidently reach for success. It is built on 30 leadership that insists on accountability and continuous quality improvement (CQI). 31 32 Leaders orchestrate the effort. They must communicate “the OHCA story” in a way that fosters 33 true engagement from PSAP and EMS personnel. The story is about much more than the 34 incidence and outcome statistics of a major public health problem: it’s about human lives. A 35 survivor who visits the alarm room or station at a chief’s invitation humanizes everything – the 36 value of such concepts as “protocol compliance” and “team choreography” become suddenly 37

EMS systems that implement and carefully measure TCPR and HP-CPR consistently save the most lives.

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real. Meeting survivors as described in the vignette above, frontline providers are truly inspired 1 to engage the challenges and change required to optimize care. 2

3 Leaders also realize that “We cannot improve what we do not measure.” They require the truth 4 about the care their agencies provide. They insist on measuring key performance indicators and 5 comparing the results to recommended standards, engaging their agencies to develop, declare 6 and refine the process of evaluation and improvement. In these ways they catalyze a culture 7 that embraces OHCA and the chance to save lives. Their agency comes to view poor CPR and 8 failure to provide CPR as a preventable harm. It identifies gaps between evidence-based best 9 practices and actual performance, defines a plan to narrow it, and provides examples of success 10 in other systems. 11 12 All members of the team are responsible for the process. This shared accountability is essential; 13 individual excellence is a fundamental building block for team success. With the push for 14 excellence, we must appreciate that perfection is a never-ending goal. Thus, we must review 15 challenges, shortfalls, and missteps in ways that instill resilience and advance care rather than 16 dispense discipline. 17 18 Leadership is responsible for interpreting results, charting the path forward, and inspiring their 19 teams to seek continual improvement. Leadership needs to recognize individual and 20 organizational success and in turn empower frontline providers to take initiative and strive for 21 best practices. This approach connects both the individual and the organization to community 22 health; it is a powerful tool for saving lives. 23 24 Note: For more on T-CPR and HP-CPR cultures of excellence, please see pages 35 and 69. 25 26

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1 PART 1: TELEPHONE CPR 2

3 1. OVERVIEW 4

5 What is Telephone CPR? 6 Telecommunicator CPR )T-CPR) or Dispatcher-Assisted CPR, is a three-step process where 7 telecommunicators: 8

o work together with 9-1-1 callers to identify potential OHCA patients 9 o provide callers with pre-arrival CPR instructions 10 o coach callers to perform continuous CPR until professional rescuers assume 11

care. 12 13 TCPR has been linked to improved patient outcomes across the worldiii iv v vi viiand is extremely 14 cost-effective: providing it requires almost no capital expense. 15

16 Purpose: The purpose of Part 1 of this document to help you start and/or improve this life-17 saving program in your 9-1-1 center. It covers: 18

o The American Heart Association Recommendations for TCPR. 19 o TCPR Protocols 20 o TCPR Training 21 o TCPR culture of excellence 22

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The Three Steps of TCPR: A Brief Overview 24

Telecommunicators must work with 9-1-1 callers to identify potential cardiac arrest 25 patients, provide pre- arrival CPR instructions, and coach lay rescuers to continue CPR 26 until professional rescuers can arrive and assume care. This section gives an overview of 27 the opportunities and challenges inherent in each of these “three phases” of TCPR. 28 29 Step 1. Identifying OHCA 30

31 Because survival depends closely on the time from patient collapse to first chest 32 compression, it is vital that telecommunicators identify OHCA as early as possible. 33 Success depends on factors both within and outside their control. For example, a caller’s 34 emotional distress and the position of the patient can challenge identification and are 35 often outside the telecommunicator’s control. However, telecommunicators do control 36 the approach they use to calm callers and to encourage them to take action. 37

Clear, concise protocols can help telecommunicators swiftly identify OHCA. This 38 document will discuss protocols in more detail in Section 4. In many cases, identification 39 is challenging and requires application of the strategies and tactics discussed in Section 40 4. For now, it should be noted that protocols should allow telecommunicators to quickly 41 identify potential OHCAs and to start CPR instructions without delay. 42

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1 Step 2. CPR Instructions 2

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After telecommunicators recognize potential OHCAs, they should provide CPR 4 instructions as soon as possible. As we will discuss later, TCPR increases the chance that 5 professional rescuers succeed in restoring circulation through HP-CPR. Often, 6 telecommunicators have to support the efforts of callers trying to get patients from a 7 bed, couch, chair, or even a toilet onto their backs for CPR. Other common barriers 8 include a caller’s fear they will hurt the patient when getting them to the floor or when 9 doing compressions. We’ll cover these and other barriers in the Training section. 10

In large majority of cases, instructions will be for compression-only CPR. Studies have 11 shown this type of CPR to be as effective as CPR with rescue breaths. The instructions 12 are also easier to deliver and easier for the lay rescuer to execute. In addition, callers 13 are less likely to refuse to do compression only CPR than they are to refuse CPR with 14 rescue breaths. 15

Step 3. CPR Coaching 16

After CPR is started, telecommunicators should stay on the line with callers to provide 17 CPR coaching and psychological support until professional rescuers assume care. This 18 function is essential: proper coaching can minimize pauses to chest compressions and 19 can help maintain good compressions rate, depth and recoil (allowing the chest to come 20 all the way up between pumps). 21

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Telecommunicators are the “first first responders.” They form a team with the caller and work together to do CPR until professional rescuers assume care.

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2. THE COMMITMENT TO ACT: CHALLENGES AND PERSPECTIVES 1

A number of practical considerations must be addressed to implement T-CPR. A number of 2 programs can offer useful strategies. 3

Challenge 1: Staffing 4 Most PSAPs face ongoing staffing challenges and may be concerned that OHCA calls will take a 5 significant amount of time and delay answering other 911 calls. 6

Things to consider: 7

o OHCA calls are infrequent: OHCA calls represent 1%-2% of all 911 calls and are 8 therefore a small impact on receiving, processing, and dispatching them. 9 10

o OHCA calls could be transferred to a designated PSAP: In Minnesota, five PSAPs 11 currently provide emergency medical dispatch (EMD) instructions for a number of 12 primary PSAPs. While the state does not mandate such arrangements, it intends to 13 pursue a more formal and inclusive EMD program. 14 15

o Wisconsin and Kentucky laws require PSAPs that do not provide TCPR instructions 16 transfer suspected OHCA calls to a PSAP that does provide TCPR instructions. 17 18

o Some PSAPs transfer OHCA calls to an EMS agency, which provides instructions and 19 coaching to callers. Parts of Michigan and New Hampshire transfer OHCA calls to 20 EMS agencies. 21 22

Challenge 2: Lack of Medical Direction 23 Many PSAPs do not have ongoing, active medical oversight. They may not know “where to 24 start” or who to contact to establish it. 25

Things to consider: 26

o 9-1-1 collaboration with local EMS agencies may provide a useful model to consider. 27 28

o Since 2017, the Alabama 911 Board has partnered with the state’s Department of 29 Public Health's Office of EMS, whose medical director reviewed and approved 30 statewide EMD protocols, including instructions for TCPR. The medical director has 31 agreed to provide medical oversight for any PSAP using these protocols. 32

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Challenge 3: Perceived Liability Concerns 1 PSAPs may be concerned that implementing TCPR may open them to liabilities. 2

Things to consider: 3

o Florida passed legislation protecting 9-1-1 agencies and telecommunicators from 4 liability (editor’s note: link will be inserted) relating to injuries resulting from the use 5 of EMD protocols, including protocols for TCPR. Minnesota has a similar law 6 protecting telecommunicators. 7 8

o EMS Medical Directors may provide liability coverage as part of their role in 9 providing medical oversight for TCPR. 10 11

o The likelihood of a successful claim in cases involving TCPR is exceedingly low when 12 following a medically-approved dispatch protocol. In fact, the failure to provide pre-13 arrival instructions is far more likely to result in a law suit as PAIs are now clearly the 14 standard of care in emergency dispatch. 15 16

o Wisconsin and Kentucky have enacted laws requiring that PSAPs provide TCPR 17 instructions on suspected OHCA calls (or transfer the call, as noted above) 18

Challenge 4: Costs 19 PSAPs of all sizes face budget constraints and some state laws allow for funding mechanisms 20

Things to consider: 21

22 o Florida allows 911 surcharge funds to be used to cover training, 23

certification/recertification, protocol systems, continuing education and labor costs 24 associated with processing 911 calls. (editor’s note: link will be inserted) relating 25 26

o A number of states (e.g., Arkansas, Indiana, Maine, Tennessee) provide funding for 27 911 training, and while not designated specifically for T-CPR training, these funds 28 uses could include it. 29 30

o Maine allows 911 surcharge funds to be used for the payment of EMD costs for all 31 initial training and recertification, EMD software licenses, set up support, annual 32 maintenance fees, and continuing education training. (editor’s note: link will be 33 inserted) 34

o In-kind forms of support (e.g., “donation” of time and resources) can be tapped to 35 assess baseline performance and process improvements that serve as impetus for 36 the provision of resources needed for full implementation. Arizona uses revenue 37 from a state tobacco tax earmarked for public health improvement to help fund a 38

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resuscitation program that includes TCPR implementation. Other states may be able 1 to access tobacco tax revenue for similar purposes. 2 3

Challenge 5: Charter/Perceived Scope of Practice 4 Many PSAPs, especially those with a Law Enforcement focus, may think TCPR is beyond their 5 scope of practice. 6

Things to consider: 7

o Most consider CPR “First Aid” under the purview of all potential rescuers rather 8 than a medical intervention that only trained medical professionals can perform. 9 This clearly places CPR instruction in the scope of telecommunicators. 10

11 o Exposure to colleagues at a Resuscitation Academy may provide examples of how 12

other PSAPs have navigated scope-of-practice concerns. 13

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Challenge 6: Use of Data 15 The Health Insurance Portability and Accountability Act (HIPAA) prescribes rules regulating the 16 use of patient health information. 17

Things to consider: 18

o HIPPA does not prevent hospitals from sharing patient outcomes with 9-1-1 centers 19 and EMS agencies who provide care for the patient. 20 21 US Department of Health & Human Services: Sharing Patient Health Outcomes 22 Information between Hospitals and EMS Agencies for Quality Improvement 23 24 US Department of Health & Human Services: Uses and Disclosures for Treatment, 25 Payment & Health Care Operations 26 27

o Because OHCA has been designated a major public health problem in Arizona, the 28 Save Hearts in Arizona Registry & Education program is able to collect HIPAA-29 exempt 9-1-1 patient data as part of a state-recognized public health quality-30 improvement program. 31 32

o Next Generation 911 Implementation: As PSAPs upgrade existing infrastructure, 33 capabilities will expand far beyond the current “voice only” environment and will be 34 able to receive, process, and share text “calls” to 911, photos, video, and digital 35 health data from a variety of sources. What changes in current T-CPR protocols will 36 be necessary to accommodate these technological changes? Addressing these 37 changes should be part of any implementation plan. 38

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1 Action Steps for Implementing TCPR 2

Make the Commitment 3 Actively involve appropriate stakeholders and individuals 4 Establish roles and responsibilities (including a plan to fund these) 5 Establish written/verbal agreement between 9-1-1 and EMS to collaborate on 6

specific tasks 7 Establish and execute a plan for implementation 8 Include, technical, administrative, operational and training components 9 Summarize scientific evidence supporting TCPR into checklists 10 Utilize AHA performance measures 11 Provide continuous feedback on performance measures to teams 12

Ten Actions to Achieve Implementation 13

Select program or programs to implement 14 Form a team or advisory board 15 Determine how to make it happen in your community 16 Set specific goals 17 Create the compelling argument to achieve buy-in from agency personnel 18 Know the performance standards 19 Consider a pilot program 20 Communicate progress within the agency 21 Communicate with the public and EMS personnel 22 Support, Advocate, Celebrate 23

3. AMERICAN HEART ASSOCIATION T-CPR PROGRAM & PERFORMANCE RECOMMENDATIONS 24 25

In 2017, the American Heart Association published 6 program and 5 performance 26 recommendations for timely delivery of T-CPR instructions. 27

28 Adopting these recommendations will give your agency a roadmap to improve your T-CPR 29 program and show a commitment to improving OHCA survival in your community. 30

31 (Editor’s Note: Figure 2 will show the six program recommendations. We will discuss the five 32 performance recommendations in connection with TCPR Quality Improvement in Section 6 on 33 pages 36-39.) 34

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Figure 2: American Heart Association TCPR Program Recommendations 37 38

39 Commitment to Telephone-CPR

• The emergency communications center will commit to providing effective T-CPR.

• The dispatch center director must

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provide leadership and hold the staff accountable for implementation.

Train and Provide Continuing Education in T-CPR for all Telecommunicators

• Require initial training for all call takers and dispatchers. Initial training will require an estimated 3-4 hours.

• Require ongoing continuing education. This will require 2-3 hours annually.

Conduct Ongoing Quality Improvement (QI) for all Calls in Which a Cardiac Arrest is Confirmed by EMS Personnel and in Which Resuscitation is Attempted

• All calls in which resuscitation is attempted must have the 9-1-1 call audited for QI purposes.

• Must collect key time intervals and reasons for non-recognition of cardiac arrest and reasons for delays.

• Individual QI review of every cardiac arrest call provided by the supervisor (or designated QI person) including helpful feedback.

• QI reports must be summarized annually and secular trends reported.

• QI reports should be used to identify training needs.

Connection to EMS Agency

• Close engagement with the EMS agency is required to link data from dispatch audio with EMS run report data.

• Linkage with EMS is required to identify the denominator of total cardiac arrest cases and the percentage of all cardiac arrests which are recognized as cardiac arrest by the telecommunicator/dispatcher.

Designated Medical Director

• There should be a designated communications center medical director who shall issue the dispatch protocols for T-CPR and be able to work closely with the EMS agencyviii ix. Ideally, there should

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be a combined medical director for the dispatch center and EMS agency.

Recognition for Outstanding Performance

• Telecommunicator recognition program for outstanding performance in the recognition of cardiac arrest and delivery of T-CPR instructions.

Reviewing OHCA recordings can be time- and labor-intensive. It is important to note that, if your 9-1-1 1 center isn’t able to review all cardiac arrest recordings as recommended, it should create a sustainable 2 plan for reviewing as many as possible. When used for process reporting and feedback with individual 3 telecommunicators, these reviews are an indispensable CQI tool. 4 5 6 7 4. PROTOCOLS 8 9 Objective: To summarize the “do’s and don’ts” in TCPR protocols. 10

11 o TCPR and Comprehensive Pre-Arrival Instructions 12

13 The formal process of providing pre-arrival Instructions (PAIs) to medical 9-1-1 callers began in 14 isolated communities in the late 1970s and has evolved to become national standard of care, a 15 public expectationx,xi,xii,xiii,xiv,xv,xvi and, in some cases, a legislative mandate. 16 17 For example, see: 18 Link to Wisconsin legislation information 19 Link to Kentucky legislation information 20

While cardiac arrest patients can benefit greatly from the provision of PAIs, it needs to be 21 stressed that cardiac arrest constitutes a small percentage of all medical calls. Skill in identifying 22 cardiac arrest and providing proper instructions to the caller requires frequent training and 23 practice. There are data to demonstrate that low call volumes are linked to poorer patient 24 outcomes.xvii For these and other important reasons, including caller, patient, and responder 25 safety, we stress the importance of implementing a comprehensive dispatch protocol process 26 that addresses safety, response allocation and priority, patient care, and information for 27 responders on all emergency medical calls. 28

However, a comprehensive dispatch protocol process is not a pre-requisite for implementing 29 PAIs for telephone CPR in your 9-1-1 center. 30

31 There are several commercial EMD programs available. Some direct telecommunicators to 32 assess scene safety before beginning the triage process. EMD programs include but are not 33 limited to: the Priority Dispatch, PowerPhone 911, and the APCO EMD program. 34

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1 Some agencies develop their own protocols under the guidance of a medical director. After 2 confirming the incident address and caller phone number, your protocols, (whatever dispatch 3 system you use) should allow telecommunicators to identify OHCA and start CPR instructions as 4 soon as possible. Protocols and telecommunicators should avoid questions that do not relate 5 directly to scene safety, patient status, response allocation, PAIs, and necessary information for 6 responders. Such questions can delay the start of CPR. In OHCA, recognition, immediate 7 dispatch and prompt delivery of PAIs are paramount to survival. 8 9 The following example shows how unnecessary questions can delay the start of CPR: 10

11 12 13 (Editor’s Note: link to sample audio file will be included in final report)

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TCPR Stage 1: Identification 16 17 Cardiac arrest can often be identified by simply understanding the scenario presented by the 18 caller, i.e., what happened? For example, the sudden, unexpected collapse of someone who 19 appeared okay just moments before strongly suggests cardiac arrest. 20 21 In addition, AHA recommends that telecommunicators ask callers two questions as early in calls 22 as possible: 23 24

o Is the patient conscious? 25 o Is the patient breathing normally? 26

27 If the answer to both these questions is “no,” then telecommunicators are advised to start CPR 28 instructions without delay. This “No, No, Go!” approach will cast a wide net to maximize OHCA 29 identification and will include patients not in cardiac arrest. Overtriage, however, is necessary in 30 life-threatening emergencies. In suspected trauma, for example, the acceptable rate of 31 overtriage is 25%-50%.xviii 32 33 Below is a link to an example of swift OHCA identification through the two-question approach: 34 (Editor’s Note: link to sample audio file will be included in final report) 35

36 (Editor’s Note: link to sample audio file will be included in final report) 37

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Protocols should help telecommunicators quickly identify OHCA and start CPR instructions as early in calls as possible

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Callers are sometimes confused by the word “conscious.” If a caller seems confused, 1 telecommunicators can follow up by asking is the patient is “awake,” as in this recording: 2 3

CR asked if patient was awake when RP

(Editor’s Note: link to sample audio file will be included in final report) 4 5 6

7 TCPR Stage 2: CPR Instructions 8 9 For adults who suddenly collapse, or who are found unconscious and/or not breathing normally, 10 instructions should be for compression-only CPR. For children, instructions should incorporate 11 rescue breathing and chest compressions, since respiratory causes of cardiac arrest are more 12 common in children. 13 14 An example of scripting for chest compressions: 15

o “Listen carefully – we can do this together” 16 o “KNEEL by his/her side.” 17 o “Put the HEEL of your hand on the CENTER of the chest.” 18 o “Put your other hand on top of that hand.” 19 o “WITH YOUR ARMS STRAIGHT, PUSH DOWN HARD AND FAST WITH THE HEELS 20

OF YOUR HANDS. Let the chest COME ALL THE WAY UP between pumps.” 21

22 TCPR Stage 3: CPR Coaching 23 24 Protocols should provide scripting for continuous, supportive CPR coaching after CPR is started. 25 Two studies show that TCPR is as effective in saving lives as bystander CPR without 26 telecommunicator instructions. This is due in part to CPR coaching - telecommunicators can 27 have a positive impact on compression rate, depth and recoil by providing feedback and 28 guidance over the phone. Below is a sample protocol for coaching callers after CPR is started. 29 30

o “Good job. Keep going. Count with me: 1,2,3,4 …” 31 o If the caller stops counting, remind them: “I need you to count out loud for me: 1,2,3,4 … 32

” 33 o At intervals, remind the caller to: 34 o “Keep your arms straight” … 35 o “Push hard and fast” … 36 o “Let the chest come all the way up between pumps” 37 o “You’re doing a great job … keep going.” 38 o If the caller complains they’re tired or that what they’re doing isn’t working, continue to 39

provide calm, assertive support. 40

Telecommunicators can have a positive impact on compression rate, depth and recoil by providing feedback and guidance until professional rescuers assume care

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1 Other considerations 2 3 Protocols should allow telecommunicators to forgo scripted questions when elements of the 4 patient’s status are obvious or known. That is, they should allow some flexibility to fast-track 5 forward in the algorithm to identify possible cardiac arrest patients. For example, if a caller says, 6 “I found my husband on the ground and I cannot wake him up,” she has indicated that the 7 patient is an unconscious adult. Requiring the telecommunicator to ask “Is he conscious?” would 8 be unnecessary. Two audio examples of such calls can be on page 20. 9

10 Protocols should also provide: 11

o simple language encouraging telecommunicators to assertively direct callers 12 o conditions under which to seek an automated external defibrillator (AED) 13 o support for AED use if an AED is acquired 14

15 Lastly, protocols should reflect the latest science investigating elements of, and barriers to, the 16 TCPR process. A listing of TCPR scientific publications can be found here. 17 18

19 5. TELECOMMUNICATOR TRAINING 20 21 22

Objective: To implement comprehensive telecommunicator training and continuing education 23 programs. 24

25 Initial training should require no less than three hours. Another two to three hours should be 26 dedicated to continuing education each year. In this section, we recommend a learning program 27 that follows the “Circle of Telecommunicator CPR” . The circle has five segments addressed 28 below: 29 30 31 32 33 34 35 36

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1. Know the Recommendations/Learn the Basics 38 39

AHA’s TCPR Program and Performance Recommendations 40 lay out the vision and methods for optimizing OHCA 41 outcomes. Please see pages 11-12 and 36-39. 42

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44 2. Practice CPR Skills 45

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1 o Telecommunicators should practice continuous compressions on a training mannequin 2

for several consecutive minutes to simulate the physical challenge of performing CPR on 3 a “real call.” Such practice can: 4

5 o give telecommunicators a deeper sense of what it means to achieve proper rate, 6

depth, and recoil. 7 8

o help telecommunicators appreciate the value of the techniques they tell callers 9 to use (e.g., how keeping your arms straight helps achieve proper depth, or how 10 not leaning on the chest helps achieve full recoil 11 12

o help establish empathy with callers and their efforts to perform continuous 13 compressions until professional rescuers assume care. 14 15

o CPR certification is not required but should be encouraged. Agencies should consult 16 local policies and laws regarding CPR certification for telecommunicators. 17

18 o If a PSAP does not have training mannequins, it can usually borrow them from an EMS 19

agency it dispatches for. 20 21

o EMS agencies can provide in-person CPR instruction. 22 23

o Several short videos freely available on the internet can supplement CPR instruction. 24 One example is available here. 25

26 27 28 29 30 31 32 33 34 35 36 3. Master 3 Stages of TCPR 37 38

Telecommunicators who understand how CPR works will have a basic medical 39 foundation on which to master the 3 stages of TCPR. For this reason, we give a brief 40 overview. 41 42

How CPR Works 43 44 Cardiac arrest, the sudden failure of all electrical and mechanical activity in the heart, results in 45 unexpected collapse. The heart may quiver for a few minutes (the “VF” rhythm noted on page 46 1), but circulation of the blood is entirely lost. 47

19

1 The time from the 9-1-1 call to the moment professional rescuers arrive at the patient’s side can 2 be 10 to 15 minutes in urban areas and even longer in rural areas. 3 4 As noted previously, the chance of survival falls rapidly in the absence of care. Bystander CPR is 5 therefore essential. It more the doubles the chance a patient survivesiii for two reasons: 6 7

1. Chest compressions generate blood flow to the heart, brain and vital organs while 8 professional rescuers rush to the scene. 9

10 2. Chest compressions prolong the duration of VF, increasing the chance for successful 11 defibrillation by lay rescuers or professional rescuers when they arrive with an AED. 12

13 It is important to note that, if a caller reports that they just saw someone collapse, that person is 14 more likely to be in VF during the call than a patient found unconscious some unknown minutes 15 later. These “witnessed” cases, then, are the patients we have the best chance of saving. 16 17 For more detail on the physiology of how CPR works, please see Appendix 1 pages 40-41. 18 19 Telecommunicators can profoundly increase rates of bystander CPR by instructing 9-1-1 callers 20 to start CPR after identifying OHCA. iv v vi vii vii Instructions should be for compression-only CPR for 21 adults who suddenly collapse or who are found unconscious and/or not breathing normally. The 22 blood flow compressions generate drops sharply with even short pauses in compressions, as 23 shown at the link below. For this reason, bystanders rescuing adults should not stop 24 compressions to give rescue breaths (unless the arrest stems from a respiratory cause such as 25 drowning). 26 27 For children, instructions should include both compressions and rescue breaths since respiratory 28 causes of cardiac arrest are more common in children. 29

30 31 32 33 34 35 36 37 How to process the 9-1-1 Call: The Three Stages of TCPR 38

39 40 Prepare for success: the telecommunicator’s mindset 41

Because OHCA comprises only 1-2% of call volume, it’s natural to assume the next call will not 42 be a cardiac arrest. Telecommunicator education should flip this mindset. Ideally, we should 43 assume that every call is a cardiac arrest until proven otherwise. This assumption can help foster 44 the “aggressive” mindset sometimes needed to identify OHCA. That is, it helps us prepare for 45 success. 46

47

Every call should be assumed to be a cardiac arrest until proven otherwise.

20

1 2

Essential importance of the telecommunicator 3 4

Your education program should discuss the essential role telecommunicators play in the Chain 5 of Survival. Telecommunicators directly contribute to patient care and outcomes. Their ability to 6 act quickly and decisively is essential in these time-critical emergencies. 7 8 Of the five links (See Section 1), telecommunicators directly influence the first four. 9 Telecommunicators: 10

11 1. receive the 9-1-1 call. 12 13

2. triage the patient and identify OHCA. 14 15

3. provide telephone CPR instructions to the caller. 16 17

4. rapidly dispatch professional rescuers with AEDs 18 19 20

Editor’s Note: Related Sidebar content 21 Training should not only provide the tools telecommunicators need to succeed – it should 22 also foster the motivation. People who see value, take pride, and feel empowered in their 23 work perform better than people who don’t. Training can cultivate these intangibles by re-24 emphasizing several points: 25

26 o The role telecommunicators play is understood and appreciated now as never 27

before. In recognizing OHCA and directing bystanders to start CPR, they facilitate 28 what has been called “the anchor link” in the Chain of Survival. It is fair to say that 29 “their time has come.” 30 31

o Telephone CPR is as effective in saving lives as standard CPR (Wu, Viereck, Ro) 32 33

34 o Telephone CPR is often more common than bystander CPR without 35

telecommunicator instructions (Wu, Viereck, Ro, Hardeland) 36 37

o In many places, survivors are twice as likely to have received TCPR than CPR 38 without telecommunicator assistance. [Wu, Viereck, Ro] 39

40 41

o Few callers understand that the person they are calling for is in cardiac arrest. The 42 telecommunicator plays a crucial role in determining the patient’s status 43 (Berdowski) 44 45

o The two-question model is highly effective in identifying cardiac arrest 46

21

1 2

o Some overtriage will happen, but CPR on a person not in cardiac arrest is not 3 dangerous [Rea]. 4 5

o Most callers are relatives or friends of the patient. They are often alone and 6 terribly distressed. Only telecommunicators can provide the immediate help they 7 need. 8

9

10 11 The Three Stages of TCPR 12 13 The “Three Stages” of TCPR can serve as the spine of your telecommunicator education 14 program. Again, these steps are: Stage 1 - Identifying OHCA, Stage 2 – CPR Instructions, Stage 3 15 – CPR Coaching. 16

17 Stage 1: Identifying OHCA 18 19 Identifying cardiac arrest is the first vital step in the TCPR process. One study found that patients 20 were over three times more likely to survive if telecommunicators simply recognized their arrest 21 during the emergency call.xix 22

Callers often report most or all of the information needed to identify OHCA after the 23 telecommunicator asks what the nature of the emergency is. Active listening, then, fostered by 24 the assumption that every call is a cardiac arrest until proven otherwise, is an essential skill. 25 Consider the following audio example: 26

27

28

(Editor’s Note: link to sample audio file will be included in final report) 29

30

Here, before we even confirm the incident location, the caller has told us that his wife (an adult) 31 has collapsed in the back yard. All we need to ask, then, is whether she is breathing normally. If 32 not, then we should start compression-only CPR instructions as soon as possible. 33

Here is another example. What information does the caller provide and what do we need to find 34 out to determine whether the patient is potentially in cardiac arrest? 35

36

(Editor’s Note: link to sample audio file will be included in final report) 37

Active listening is an essential skill that can expedite OHCA identification in the opening seconds of a call.

22

Triage 1

Telecommunicators begin the triage process after confirming the incident location and 2 the caller’s phone number. The goal of triage is to determine the level of help to 3 dispatch based on the chief complaint, signs, and symptoms the caller reports. 4

The first step in the triage process, and in identifying OHCA, should be determining if 5 the patient is conscious. If the caller reports that the patient is conscious, OHCA can be 6 ruled out and the telecommunicator can move forward exploring the chief complaint. 7

If the caller reports the patient is not conscious, however, then telecommunicators 8 should immediately ask if the patient is breathing normally. If the answer is also “no,” 9 then telecommunicators should start CPR instructions without delay. 10

11 In a perfect world, callers would provide clear, concise, “yes” and “no” answers to these 12 questions. In the real world, of course, their answers are often unclear even when 13 patients are in cardiac arrest. Consider this compilation of recordings: 14 15

(Editor’s Note: link to sample audio file will be included in final report) 16

17 18 19

Such challenges are among several common barriers to recognizing OHCA. We will now 20 take a look at such barriers and the tactics telecommunicators can use to overcome 21 them. 22 23

24 Common barriers and tactics for assessing patient consciousness 25

26 Barrier 1: Emotional distress 27 The large majority of OHCAs occur in homes. Callers are usually family members or 28 friends of the patient and are therefore often in grave emotional distress. This can 29 make communication very challenging. Consider the following audio recording: 30 31

32 (Editor’s Note: link to sample audio file will be included in final report) 33

Tactic 1: Be Assertive 34 Telecommunicators should use plain language and a persistent, assertive tone when 35 needed to focus a caller’s attention. Note the tone the telecommunicator used in 36 the recording and her success in getting the caller focused. 37 38 39 Barrier 2: The caller does not understand the word “conscious.” 40

Callers are not always clear what “conscious” means. 41

23

Tactic 2: Rephrase the question 1

To clarify their meaning, telecommunicators can use alternate wording such as: 2

“Is the patient awake?” or 3

“Does the patient respond to you when you talk to them or touch them?” 4

Barrier 3: Open eyes and brief, seizure-like movements 5

Callers sometimes report that the patient’s eyes are open, or that the patient is 6 moving. A report of a patient’s eyes being open, however, should not be mistaken 7 for consciousness. Minor movements by OHCA patients are not unusual. Patients 8 may display brief movements associated with, and often mistaken for, a seizure. 9 These movements are not purposeful, however, and do not indicate consciousness. 10 A conscious patient will respond, if only in a small way, to verbal or physical stimuli. 11

Tactic 3: Shake and shout 12

Telecommunicators can tell callers to shake patients by the shoulders and shout 13 their name to and see if they respond. 14

15

16

17

Common barrier and tactic for assessing patient breathing 18 19

Barrier 4: Agonal Breathing 20

If the patient is reported unconscious, the telecommunicator should ask if the 21 patient is breathing normally. About 40% of OHCA patients exhibit abnormal, agonal 22 breathing (or “gasping”) when EMS arrives [REF]. 23

Agonal breathing is common in the first few minutes of cardiac arrest. It is caused 24 by brainstem reflexes and is the body’s last-ditch effort to deliver oxygen to the vital 25 organs during OHCA. It is completely ineffective. It is typically slower than regular 26 breathing and presents in a variety of ways. Here are a few examples of what agonal 27 breaths can sound like over the phone: 28 29

30

Agonal 1.wav Agonal 2.mp3 Agonal 3.mp3

31

(Editor’s Note: link to sample audio file will be included in final report) 32

These breaths can confuse callers and telecommunicators alike, who may mistake 33 them for signs of life. The presence of these breaths can thus obstruct the TCPR 34 process. Yet patients with agonal breathing have a greater chance of surviving than 35

24

patients without it because agonal breathing is linked to residual oxygen in the 1 brain. It is therefore imperative that training programs address how 2 telecommunicators can recognize agonal breathing. 3

Telecommunicators can identify agonal breathing not only by the sounds patients 4 make, but also by the descriptions callers use to describe it. Figure 2 shows the 5 frequency with which callers used certain terms to describe agonal breathing in one 6 study. 7

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Figure 2: Frequency of terms callers use to describe abnormal breathingxx 23 24

25 26

27 These audio recordings provide a few examples of such descriptions: 28

25

1 2

Agonal described 1.wav

Agonals described 2.wav

Agonals described 3.mp3 3

4

(Editor’s Note: link to sample audio file will be included in final report) 5

6

Tactic 4: Ask the caller to put the phone by the patient’s mouth 7 8 If telecommunicators aren’t sure whether the patient is breathing or breathing 9 normally, they can direct the caller to put the phone by the patient’s mouth so 10 they can listen for the breathing firsthand. Here is an example: 11 12 13

14 (Editor’s Note: link to sample audio file will be included in final report) 15

16 If telecommunicators hear neither breathing nor agonal respirations, they should 17 conclude the patient is not breathing normally. Background noise in the PSAP, it should 18 be noted, can make it hard for telecommunicators to listen for breathing. 19 20 Tactic 4a: Ask the caller to observe the patient’s chest, watching for it to rise and fall 21 normally and rhythmically. 22 23 If telecommunicators are unclear whether a patient is conscious and/or breathing 24 normally, they should start CPR instructions as soon as possible – “when in doubt, there 25 is no doubt.” The chance that chest compressions injure adults not in cardiac arrest is 26 very small – one study found that the chance of injury (eg, rib fractures) to adults not 27 in cardiac arrest was just 2%.xxi The study found zero cases where patients sustained 28 any serious injury, such as damage to internal organs. 29

30

31

When in doubt, there is no doubt: start CPR instructions right away!

“Gasping” is the most common term used to describe abnormal breathing

26

1 Barrier 5: Caller is a health care professional 2 3 Telecommunicators should not make assumptions about the competency of callers or 4 veer away from protocols call simply because a caller is a health care professional. 5 6 Tactic 5: Treat all callers the same, even if they are health care professionals. Assess 7 consciousness and breathing according to your protocol and, when indicated, start CPR 8 instructions. 9 10 Summary 11

12 Stage 1 barriers and tactics can be summarized as follows: 13

14 15

Barrier Tactic Caller emotional distress Be assertive Caller does not understand “conscious” Rephrase the question (e.g., “Is he awake?”) Open eyes, seizure-like movements Shake and shout Agonal breathing Ask to hear patient’s breathing; look to see

if chest rises and falls normally and rhythmically

16 17 18 Stage 2: CPR Instructions 19

20 After telecommunicators recognize potential OHCAs, they should provide CPR 21 instructions as soon as possible. Because the majority of calls come from cell phones, 22 telecommunicators should ask callers if they are on a cell phone and, if so, direct them 23 to put it on speaker function. This helps communication while callers attempt to follow 24 instructions. As with OHCA identification, however, there are barriers to providing CPR 25 instructions. 26

27 There are many reasons why callers may hesitate, or even refuse, to perform CPR. They 28 may lack of confidence in their ability to perform CPR or fear they may hurt the patient, 29 believing the patient is not really in arrest. They may think they have to perform rescue 30 breaths or may think the patient is already dead. 31

Telecommunicators can help overcome each of these barriers. 32

33 Barrier 1: Caller hesitates or refuses instructions 34 35 Tactic 1: Be decisive 36

27

A telecommunicator who is decisive and confident in giving instructions will help the 1 caller overcome hesitation and doubt in their ability to perform CPR. By providing 2 encouragement and support, the telecommunicator creates an informal partnership 3 with the caller which will increase the caller’s confidence to perform CPR. 4 Barrier 2: Patient Positioning 5 6 Perhaps the most challenging barrier to starting instructions is patient positioning. CPR 7 should be done with patients flat on their back on a hard, flat surface (usually the floor), 8 but patients are often found on a bed, couch, chair, or even the toilet. Sometimes they 9 are wedged between any of these and a wall. 10 11 Callers often say the patient is too heavy to get to the floor. Consider this example: 12 13

(Editor’s Note: link to sample audio file will be included in final report) 14

15

One study found that compressions were about half as likely to start and were delayed 16 by more than one-and-a-half minutes because callers either couldn’t get patients into 17 position or took considerable time to do so.xxii 18

28

Tactic 2: Get help 1 2 Callers in emotional distress may not think to get help from people (eg, a family 3 member) readily available to assist. Telecommunicators should ask “Is there anyone 4 there who can help you?” Patients are far more likely to receive compressions when 5 callers facing this barrier have at least one other person present. 6 7 Tactic 2a: Sheet drag 8 9 If the patient is on a bed, telecommunicators can advise callers to grab and drag the 10 sheet they’re lying on off the bed. 11 12 Tactic 2b: Insist and assure 13 14 Telecommunicators should encourage and support callers in their efforts to position 15 patients. Sometimes telecommunicators must simply insist that callers get patients to 16 the floor and assure them they can succeed. It may be said that callers don’t always 17 know their own strength. Females in one study were as likely to get males to the floor as 18 males were to get females to the floor [Langlais]. 19 20 Telecommunicators, however, must be aware of the impact of time on the patient’s 21 chance of survival There are times when callers simply can’t get patients to the floor. In 22 these cases, CPR should be started with the patient on the bed. While not ideal, the 23 choice here is no CPR or some CPR. Always attempt CPR when possible. 24

25 Barrier 2: Fear of hurting patients when getting them to the floor 26 27 Callers are often afraid they will hurt patients (especially their heads) when trying to get 28 them to get them to the floor. 29 30 Tactic 2: Reassure the Caller 31 32 While the caller’s concern is understandable, reassure them they will not hurt the 33 patient and continue with directions to move the patient to the floor. 34 35

36 37 38 39 40

41 42

29

Summary: Step 2 barriers can be summarized in the following table 1 2

Barrier Tactic Caller refuses instructions Be decisive Patient positioning Get help

Sheet drag Assist and assure

Fear of hurting patient Reassure the Caller 3

4 Compression-only CPR Instructions 5

6 In the vast majority of adult OHCAs, telecommunicators should provide instructions for 7 compression-only CPR (NOTE: In a small minority of cases, OHCAs may stem from an obvious 8 respiratory cause such as drowning. In these cases, telecommunicators should provide 9 instructions for conventional CPR, or CPR with compressions and rescue breaths. Please see 10 Appendix 2 for more on conventional CPR.) Patients have enough oxygen in their lungs and 11 blood to keep the vital organs healthy for several minutes if compressions are performed to 12 circulate the blood. 13 14

There are 3 key components in lay rescuer chest compressions: compression rate, 15 compression depth, and recoil. 16

17 Compression Rate 18

19 o A rate of 100 – 120 compressions per minute (cpm) is optimalxxiii 20

21 o Metronomes are inexpensive. Several free metronome desktop and smart 22

phone applications are available. 23 24

o To confirm that the caller has begun compressions, and to ensure they are 25 at the appropriate rate, the caller should be asked to count out loud. 26 Counting out loud may tire the caller though, so it is not necessary for them 27 to count for the duration of the call. The goal with asking the caller to count 28 out loud is to ensure compliance with instructions and to confirm that the 29 caller is delivering compressions at the appropriate rate. Once that has been 30 established, the telecommunicator may take over counting for the caller. 31

32 Compression Depth 33

34 o Evidence suggests that proper CPR compression depth is associated with 35

survival. A depth of 2” is optimal, but how is a caller to be expected to 36 assess that depth? The reality is, they really can’t. So, when providing 37

30

instructions, callers should be encouraged to “push as hard as you can.” 1 With lay rescuers, there is little concern that they will push too deep. In fact, 2 typically callers do not push deep enough. 3

4 5 Compression Recoil 6 7 8

o During the compression phase, oxygenated blood is moved out of the heart 9 and lungs to the brain and other vital organs. However, it is only in the 10 decompression phase (“recoil”) that blood comes into heart. When the 11 chest recoils, decreased pressure in the chest cavity creates a vacuum, 12 causing the heart and lungs to refill with blood that will once again be 13 moved through the body with the next compression. 14

15

16 Stage 3: Continuous CPR Coaching after CPR has started 17

18 The Problem with Pauses in Chest Compressions 19

20 When proper compressions are delivered, it will take approximately 20 compressions before 21 sufficient pressure is created to begin circulating blood through the body. 22

23 If compressions are stopped or interrupted, it takes only 3 seconds for blood pressure to fall 24 to zero. Once chest compressions have begun, it is very important telecommunicators not 25 distract callers (by asking unnecessary questions, for example) and lead them to pause their 26 compressions. 27

28 Telecommunicators should help callers create and maintain proper compression rate. 29 Metronomes, freely available for desktops and smart phone apps, can help. Following their 30 beat, telecommunicators can set the rate and have callers take over the counting. This 31 allows the telecommunicator to monitor the rate and encourage callers to speed up or slow 32 down as needed. The telecommunicator should also periodically remind callers to push 33 “hard” or “deep” and to let the chest come all the way up between pumps. (Please see 34 sample scripting for coaching in the Protocols section on page 15. 35 36 Continuous CPR coaching may explain studies finding that telephone CPR is as closely 37 associated with improved patient outcomes as bystander CPR is.vii xxiv 38

39

Metronomes are freely available and can help guide the rate of chest compressions

31

1 Telecommunicators can assist rescuers already doing CPR when a 9-1-1 call is received. 2 Telecommunicators should ask callers to bring the phone near the patient and to count out 3 the compression rate. Whether the person doing CPR is a lay or professional rescuer (e.g., a 4 nurse in a medical facility or nursing home), telecommunicators can have a positive impact 5 on CPR quality through coaching. 6 7 Here is an example of continuous coaching for several minutes before professional rescuers 8 assume care: 9

10 11

(Editor’s Note: link to sample audio file will be included in final report) 12

13

14

Additional considerations (Sidebar Content) 15 16

o Automated External Defibrillators 17 18 o Early T-CPR will help keep oxygenated blood circulating to the vital 19

organs. Automated External Defibrillators (AEDs) applied by lay rescuers 20 can restart the heart. As a general rule, however, telecommunicators 21 should only ask if an AED is available if the event is in a public location 22 with more than one lay rescuer present. The priority should be on 23 continuous chest compressions. 24 25

o AEDs are commonly in schools, sports arenas, public buildings, airports, 26 shopping malls, and department stores 27 28

29

o Dispatching of Resources 30 31 o Telecommunicators must quickly dispatch EMS and law enforcement 32

responders (when appropriate) 33 34

o Once the event location has been verified and it is known the patient is 35 unconscious, sufficient information has been obtained to initiate a call 36 for service and dispatch help. 37

38 o Telecommunicators should notify EMS that CPR is in progress when lay 39

rescuers start compressions. This directly affects the mindset of 40

32

responders on route to the scene, particularly if the call starts as a 1 “Chest Pain” or “Cardiac Incident” complaint. 2

3

4. Simulate TCPR 4

5

6 Training should include simulation of suspected OHCA calls. Simulations allow 7 telecommunicators to apply their knowledge in environments where they can safely 8 learn from mistakes and oversights. 9 10 Simulations can be based on real OHCA calls and should present scenarios with different 11 learning objectives. Simulate not only “typical” cases (e.g., cases where the patient is a 12 male in his 60s who suddenly collapsed and requires compression-only instructions) but 13 also less common ones (e.g. cases where the patient is a child, where a caller objects to 14 doing CPR, where a language barrier complicates communication, or where an adult was 15 apparently choking). 16 17 Simulations can be done in a number of ways. Telecommunicators at their terminals can 18 field mock OHCA calls from colleagues to practice using protocols and call-handling 19 skills, for example. Alternatively, colleagues can sit back-to-back, one person with a 20 caller’s script, the other with TCPR protocols to choose from given the situation the 21 “caller” describes. 22 23 Simulations should encompass each of the Three Stages of TCPR. That is, they should 24 require telecommunicators to identify OHCA, start CPR instructions, and provide 25 continuous coaching for several minutes. 26 27 After such exercises, colleagues should debrief in small-groups where they can 28 challenge, learn from, and support each other. They can then run the simulations again, 29 applying feedback and lessons learned. 30 31 TCPR practice through simulation is important in light of data suggesting patient 32 outcomes may be linked to the number of OHCA calls a telecommunicator processes in 33 a given period of time.xxv Telecommunicators should process at least 10 OHCA calls per 34 year, either real or simulated. 35

36

37 38

5. Measure and Improve 39 40

Performance measurement is essential for performance improvement. It is important to note 41 that performance review should occur in a non-punitive environment – the objective is to 42

33

teach, encourage, and support, not punish. While not strictly part of TCPR training, 1 measurement should be central to a telecommunicator’s continuing education. It provides 2 essential feedback that can take three broad forms: 3

4 o Standardized process reports to share with staff on overall performance on key 5

TCPR measures. These measures shed light on collective strengths and weaknesses 6 and are detailed in the TCPR Quality Improvement section 36-39. 7 8 A free reporting template is available here. 9 10

o Standardized audio reviews of individual telecommunicator performance on OHCA 11 calls. These reviews can be conducted by supervisors, peers, or by the 12 telecommunicators who processed the call themselves. PSAPs should try to conduct 13 these reviews within a week and no longer than a month from the call. In general, 14 the sooner a review occurs, the more effective it is. 15

16 Free standardized review form is available here and here. 17 18

o Real-time feedback on call handling as telecommunicators process OHCA calls. 19 20

Other Topics to Consider (Sidebar Content) 21 22

23 o There should be 2 to 3 hours of continuing education annually. Learning sessions 24

should be frequent and fairly short. We recommend 30 to 45-minute increments at 25 least quarterly throughout the year. In addition to reviewing standard process 26 reports or sharing insights gained through audio reviews, these sessions can cover 27 such topics as: 28

29 o Unusual circumstances that pose challenges to the delivery of T-CPR 30

instructions. These include: 31 32

o Patient’s with DNR/POLST orders 33 o Patient’s on ventilators 34 o Post-Op patients 35 o Obvious DOA 36 o Electrocution 37 o Drowning 38 o Strangulation 39 o Two rescuer-ventilations 40 o Cardiac arrest secondary to trauma 41 o Pregnant patients 42 o Obese patients 43 o Stoma patients 44

45 o Critical Incident Stress Management 46

34

1 PSAPs need to emphasize the importance of caring for one’s mental health. 2 Providing PAIs (and perhaps most severely, PAIs for TCPR) exposes 3 telecommunicators to acutely stressful circumstances that sometimes call for 4 immediate debriefing and support. Continuing education sessions are a chance to 5 point telecommunicators to mental health resilience and support resources. For 6 more on Critical Incident Stress Management, please see Appendix 3, page 47 7

8 6. ACHIEVING A TCPR CULTURE OF EXCELLENCE 9 10

11 We described the importance of leadership, accountability, and continuous quality 12 improvement in creating a “culture of excellence” on page 3. In this section, we note: 13

14 o how PSAP leaders can build necessary bridges between stakeholders across the 15

Chain of Survival 16 o recommended elements of TCPR CQI 17 o additional steps PSAPS can take toward a culture of excellence 18

19 o Building Bridges 20

21 Leaders can foster accountability and essential cooperation among PSAPs, EMS agencies and 22 hospitals by convening review committees to evaluate OHCA events, outcomes, and 23 opportunities to improve care. The committee can help celebrate successes and advise 24 executive stakeholders of unmet needs. Committee members should include: 25 26

o PSAP operational telecommunicator representative 27 o PSAP QI representative 28 o EMS agency operational (paramedic, EMS Lieutenant, etc.) representative 29 o EMS agency QI representative 30 o Medical Director/Oversight representative 31 o Hospital Emergency Room operational (RN, paramedic) representative 32 o Hospital QI representative 33

Leaders can also convene executive committees to oversee policy resource direction. An 34 executive committee could include: 35

o Medical Director/Oversight executive 36 o PSAP QI representative 37 o PSAP agency Director 38 o EMS agency QI representative 39 o EMS Chief 40 o Emergency Room Clinical Manager 41 o Hospital QI representative 42

43

35

The PSAP and EMS QI representatives should participate in both the review and executive 1 committees. This not only gives executives an opportunity to learn from the operational 2 perspective; it also indirectly provides a sense of empowerment and a voice to the “front 3 line” 9-1-1 and EMS personnel. The executive committee can assess recommendations from 4 the review committee, approve policy, and provide resources to improve OHCA care and 5 outcomes. 6

7 o Recommended Elements of TCPR CQI 8

9

CQI is, by definition, ongoing and devoted to measuring and improving care. Importantly, it 10 is meant to support and encourage telecommunicators in their work, not punish them. 11

Measuring TCPR process and patient outcomes is central to assessing quality of care. It 12 sheds light on deficiencies and inspires improvement in both process and outcomes. Please 13 see page 33 for the different forms CQI can take as part of continuing education. 14

15

16

17

18

19

20

21

22

23

24 25 26 27 28

Figure: A model for CQI. Data collection, reporting and feedback to individual 29 providers can help agencies refine their regular trainings in an ongoing effort to 30 enhance OHCA care. 31

32

33 34

o TCPR Quality Improvement: Evaluating OHCA audio recordings for benchmarks/barriers 35 36

Data Collecti

Feedback (individu

Reporting/

Training/ Retrainin

36

Ideally, PSAPs can capture and evaluate all OHCA calls in the region they serve. There 1 are an estimated 55 OHCAs per 100,000 people.xxvi xxvii 2 3 Below is a summary of the 5 AHA-recommended performance metrics for TCPR. These 4 metrics should serve as the basis of your TCPR QI program. For more information on 5 these recommendations, please see: 6 https://cpr.heart.org/AHAECC/CPRAndECC/ResuscitationScience/TelephoneCPR/Meetth7 eTaskforce/UCM_492699_T-CPR-Taskforce.jsp 8

9 o Recommendation 1: Percentage of total OHCA Cases Correctly Identified by 10

Telecommunicators 11 12

o Definition: Telecommunicator recognized / total OHCA (confirmed by EMS 13 impression) 14 15

o Numerator: Number of QI reviewed EMS confirmed OHCA with recognition 16 noted. (Reminder: the numerator is the top number in a fraction. For example, 17 in the fraction ¼, the numerator is 1 and the denominator is 4.) 18 19

o Denominator: EMS confirmed OHCA 20 21

o A Cardiac Arrest Registry to Enhance Survival (CARES) or CARES-like OHCA data 22 registry should be in use in the EMS system(s) your PSAP serves. 23 24

o Performance Goal 75% 25 26 27

28 o Recommendation 2: Percentage of Recognizable OHCA Cases Correctly Identified by 29

Telecommunicators 30 31

o Definition: Telecommunicator recognition / number of cases deemed 32 identifiable. 33

o Numerator: Number of QI reviewed EMS confirmed OHCA with recognition 34 noted. 35 36

o Denominator: Number of QI reviewed EMS confirmed OHCA deemed 37 identifiable by supervisor. 38

39 o Exclusions from denominator: 40

41 o 3rd Party calls 42 o Hang Up 43 o Hysterical/Extreme Emotion 44 o CPR in progress 45 o Language barrier 46 o Other circumstances supervisor deems “unidentifiable” 47

48

37

o Performance Goal: 95% 1 2

3 o Recommendation 3: Percentage of Call Taker Recognized OHCA Receiving T-CPR 4

5 o Definition: Number of telecommunicator recognized OHCA cases receiving call-6

taker directed T-CPR / number of QI reviewed EMS-confirmed OHCA with 7 recognition noted where call taker directed TCPR is performed. 8 9

o Numerator: Number of QI reviewed EMS confirmed OHCA with recognition 10 noted where call taker directed T-CPR is performed. 11

12 o Denominator: Number of QI reviewed EMS confirmed OHCA with recognition 13

noted. 14 15

o Exclusions from denominator: 16 17

o Caller is unable to physically perform CPR (i.e., caller not with patient) 18 o Caller is unable to get patient into position for CPR due to physical limitations 19 o Caller refuses to do CPR 20 o Scene unsafe for CPR to be performed (trauma, disaster scenario) 21 o Caller disconnected 22 o Other circumstances supervisor deems T-CPR could not be performed 23

24 o Performance Goal: 75% 25

26 27 28

o Recommendation 4: Median Time Interval Between 911 Call and OHCA Recognition 29 30 o Definition: Median amount of time in second between 911 call connected and 31

OHCA recognition. 32 o Benchmark: < 120 seconds (less than 60 second from address acquisition to 33

telecommunicator recognition of OHCA.) 34 35

36 o Recommendation 5: Median Time Interval Between 911 Call and First TCPR Directed 37

Compression 38 39

o Definition: Median amount of time in seconds between 911 call connected and 40 first CPR compression directed by telecommunicator 41

42 o Benchmark: < 180 seconds (less than 120 seconds from address acquisition to 43

first CPR compression directed by the telecommunicator) 44 45

46 o Additional considerations 47

48

38

o Frequency of barriers to TCPR 1 2

It is helpful to track how often you identify particular barriers to TCPR. This can 3 inform continuing education. For example, if you notice that “distressed caller” 4 is a frequent barrier, you can emphasize the importance of, and techniques for, 5 managing distressed callers. 6

7 o A data collection template, dictionary and video tutorial are available at 8

https://mycares.net/ 9 10

o A QI reporting template is available at 11 https://azdhs.gov/preparedness/emergency-medical-services-trauma-12 system/save-hearts-az-registry-education/index.php#dispatchers-13 quality-improvemet 14

15 16

17 o Additional steps PSAPS can take toward a culture of excellence: 18

19 o Make a clear statement of mission and specific goals 20 o Come to a clear understanding of why time to care is so important in OHCA 21 o Create a visible presence of leaders. Have PSAP staff met them 22 o Do not hand out discipline (unless an incident involves clear violation of policies) for 23

mishandled calls. Instead ask: How can we do better? What can we learn? 24 o Make sure telecommunicators are aware of AHA performance standards 25 o Provide recognition and awards for excellent call-processing 26 o Introduce telecommunicators to survivors 27

28

29 30

31 32

33 34 35 36 37 38 39 40 41 42 43 44 45 46

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APPENDICES 1 2 3 Appendix 1: The Physiology of OHCA 4 5

Sometimes in cardiac arrest, the ventricles, or lower chambers of the heart, cease to 6 contract normally and begin to quiver or “fibrillate.” This is known as ventricular 7 fibrillation (VF). In other cases, pumping becomes weak or absent and the person looses 8 consciousness while the electrocardiogram present itself from almost normal to a flat 9 line (asystole) 10 11 A normal heart rhythm looks like this on an electrocardiogram: 12 13

14 15 16 VF looks like this: 17 18

19 20 21 This rhythm (and pulseless ventricular tachycardia, or pVT) results in immediate loss of 22 circulation. There is no blood flow to the heart, brain, or vital organs and patients 23 suddenly collapse. They are unconscious and often present with abnormal breathing or 24 brief, seizure-like symptoms. Without immediate medical care, they die within minutes. 25 26 Because VF and pVT can be converted to a normal rhythm through defibrillation, 27 however – that is, because they are “shockable” – these patients are more likely to 28 survive than patients found with non-shockable rhythms. 29 30 VF decays in a matter of minutes into asystole, a non-shockable waveform that looks 31 like this on an electrocardiogram: 32 33

34 35 36 This decay, coupled with EMS response intervals that can be 10 to 15 minutes when the 37 time from 9-1-1 call-receipt to arrival at a patient’s side are included, explains why 38 overall OHCA survival is so low. 39 40 41 42

40

Chest compressions prolong and even “energize” the VF waveform. Consider this 1 graphic 2 3

4 5

The first panel shows a VF waveform at 1 min with no CPR. The second panel shows the 6 waveform at 2 minutes with no CPR. The third shows the waveform at 13 min after 3 7 min of CPR. The waveform in third panel resembles the waveform in the first panel, 8 shortly after arrest onset. This “newly energized” waveform explains why compressions 9 increase the chance professional rescuers succeed in defibrillating the heart. 10

11 12 13 Appendix 2: Conventional CPR (CPR with compressions and rescue breaths) 14

15 o When? 16

17 o Conventional CPR instructions should be provided for instances when 18

cardiac arrest is secondary to respiratory arrest or oxygen deprivation, such 19 as: 20 21

• Choking 22 • Drowning 23 • Hanging 24 • Smoke inhalation 25 • Carbon monoxide poisoning 26 • Drug overdose 27

o Furthermore, a child in cardiac arrest should always receive chest 28 compression plus ventilation instructions. Cardiac arrest in a child is more 29 likely caused by choking or a respiratory event compared to adult cardiac 30 arrest. For this reason, instructions for these patients will still include 31 instructions for ventilations. 32

33 o Compression to Ventilation Rate 34

35 o When appropriate, the following compression to ventilation rate should be 36

applied (single rescuer scenario): 37 • Neonate/Newborn 3:1 38 o Infants [mention: on table or floor, 1 day – 1 year 30:2 39

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o Child, 1 – 12 years old 30:2 1 o Adults 30:2 2

3 Appendix 3: Critical Incident Stress Management 4 5

The reality of cardiac arrest calls is that we will lose more people than we save. 6 This can take an emotional toll on your employees. You must care for your most 7 valuable resource, your telecommunicators. Training that offers insight and 8 awareness about critical incident stress, including available resources, such as 9 EAPs, peer support groups, or department chaplains should be included in this 10 curriculum. 11

12 Call centers should provide mental health resilience and support resources for 13 telecommunicators. The provision of pre-arrival medical instructions (and 14 perhaps most severely, instructions for TCPR) can expose those involved to 15 acutely challenging and stressful situations. The impacts of secondary 16 psychological trauma include in emotional duress experienced by the 17 telecommunicator. The non-visual nature of the work can on one hand provide 18 a psychological buffer but can also increase the impact on the 19 telecommunicator as they try to visualize the scene. In addition, the auditory 20 component becomes highly accentuated for the Telecommunicator and has a 21 stronger potential for compounding vulnerabilities to secondary trauma. 22 23 If possible, mental health resilience training that includes education about 24 physiological stress reactions and how to best manage these reactions, should 25 be provided to telecommunicators prior to their first interaction with a T-CPR 26 situation. In addition, an infrastructure of mental health professionals certified 27 in psychological trauma treatment with evidence-based solutions such as EMDR 28 (Eye Movement Desensitization Reprocessing) should be established as early as 29 possible for assisting the Telecommunicators if they experience difficulty 30 managing stressors secondary to the provision of T-CPR. 31 32 Two resources available for more information are the 9-1-1 Wellness website 33 (https://911wellness.com/) and the National Emergency Number Association 34 (NENA) Standard on 9-1-1 Acute/Traumatic and Chronic Stress Management 35 NENA-STA-002.1-2013 36 37

38 39 40

41 42 43

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1 2 Appendix 4: History of Telephone CPR 3

4 5

Paramedic medical responses for out of hospital cardiac began in the early 1970s and it soon became 6 apparent that a short time from collapse to the onset of CPR was strongly associated with survival. The 7 first community wide effort to train the general public in CPR started in Seattle in 1973. 8

9 Around 1975, a paramedic in Phoenix, Arizona gave unscripted instructions to the mother of a non-10 breathing baby and the child survived. The fire chief then instructed the dispatch center to routinely 11 provide such pre-arrival instructions over the phone; the unscripted program was called “Medical Self 12 Help.” 13 14

15 In 1978, scripted protocols were introduced in the Salt Lake City, UT fire department. These protocols 16 contained specific questions, instructions, and response codes to aid callers and prioritize responses. A 17 formal training program for emergency medical dispatchers was introduced in Utah in 1979. In 1978, a 18 Medical Advisory Flip File was adopted in the state of Illinois. 19

20 In the early 1980’s, a number of places throughout the country, including King County, WA, Aurora, CO, 21 and Salt Lake City, UT began using scripted instructions to address cardiac arrest, and other major 22 problems like choking and childbirth. 23 24

25 The King County group trained dispatchers to recognize cardiac arrest over the phone and to provide 26 scripted instructions to the caller. The scripted instructions were pilot tested to devise the clearest 27 instructions using the fewest words. The program was a success. Rates of bystander CPR increased 28 dramatically and the survival rate from cardiac arrest rose. Within a few years 50% of bystander CPR was 29 solely the result of the telephone instructions. The instructions helped both callers with no prior 30 training as well as refresh the skills of individuals who had taken a prior CPR course. 31

32 In 1983, Utah became the first state to formally require the use of medically approved dispatch 33 protocols and established the first certification program for emergency medical dispatchers. Shortly 34 thereafter, the United States Department of Transportation (USDOT) issued both a curriculum and a 35 sample protocol based on a combination of the Salt Lake City Protocol, the Illinois Medical Advisory Flip 36 File, and the Utah State curriculum. 37 38

39 In 1989, the National Association of Emergency Medical Services Physicians issued a position paper 40 stating that pre-arrival instructions were a mandatory component of every medical dispatch center and 41 pre-arrival instructions, when provided by properly trained emergency medical dispatchers, were safe, 42 effective, and a moral necessity. In 1990, the American Society for Testing and Materials (ASTM), under 43 a mandate from the USDOT, issued a practice standard for emergency medical dispatch. This standard 44 was re enforced in 1994 when ASTM released two more practice standards, one for emergency medical 45 training, certification, and curriculum, and one for management and quality assurance. 46

47

43

Further studies over the past 30 years demonstrated the safety of telephone CPR, identified barriers to 1 delivering instructions, helped refine the instructions, and shortened the time from call to beginning 2 chest compression. In 2017 the rate of bystander CPR in Seattle and King County was 75% for cardiac 3 arrest associated with ventricular fibrillation (VF) with approximately half resulting from bystander 4 instructions. 5

6 National awareness of telephone CPR increased as scientific studies demonstrated utility and led to 7 endorsements for the American Heart Association and incorporation of instructions into most 8 emergency center protocols. The Resuscitation Academy since its inception in 2008 actively promoted 9 telephone CPR as an effective step in improving community survival rates. In 2015 the Institute of 10 Medicine recommended NHTSA take the lead to promote telephone CPR and in 2017 the American 11 Heart Association issued telephone CPR program guidelines and performance goals. Most recently, 12 several more states have adopted or are considering legislation requiring training in telephone CPR for 13 emergency telecommunicators. 14

15 16 Appendix 5. TCPR resources 17 18 The following links provide additional TCPR training and CQI support: 19

http://www.resuscitationacademy.org/ 20

http://cprlinktolife.com/ 21

https://mycares.net/ 22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

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1

2

PART 2: HIGH-PERFORMANCE CPR (HP-CPR) 3

4

1. OVERVIEW 5 6

o What is HP-CPR? 7 8

• HP-CPR is an expertly-performed, choreographed and measured OHCA response 9 consisting of individual and team performance that meets or exceeds current evidence-10 based performance recommendations. 11

• HP-CPR is the foundation of all successful resuscitation and is the most important 12 therapy in treating OHCA. Other interventions, such as advanced airway management 13 and drug administration, should never interrupt CPR or compromise chest compression 14 quality. 15

• Current guidelines and collective experience suggest measuring detailed performance 16 metrics in these key areas of HP-CPR: 17

18

o Table 1: Individual and Team Performance Metrics 19 20 21

Individual Performance Definitions / Notes Compression Rate Number of compressions per minute Compression Depth Depth of each compression Chest Recoil Full recoil of compressor’s hands off the chest Ventilation Rate Number of ventilations per minute Ventilation Volume Volume of each positive pressure ventilation Real-time CPR performance feedback Use of feedback or prompt devices that enhance

real-time performance (e.g. Metronome, puck) 22 23

Team Performance Definitions / Notes Team Roles Defined Pre-Arrival Compressor, Airway, Monitor etc. Team Roles Choreographed In Pediatrics, include a pre-arrival discussion of

dosing and equipment sizing Compression Fraction Affected by 4 items below

Percentage of ongoing compressions during cardiac arrest, over a period where compressions are indicated

• Efficient rotation of compressors --- • Minimization of all pauses in compressions --- • Prioritization of compressions over ---

45

advanced airway • Utilization of closed-loop communication --- o The importance of pre-planning 1 2

Pre-arrival role determination is critical for all arrests, and all patients should receive the same 3 high level of CPR irrespective of their age. While adult pre-planning is characteristically non-4 verbal, performance on pediatric calls will benefit from an intentional pre-arrival discussion that 5 explicitly verbalizes equipment size, defibrillation values, and medication volumes. 6

7 o Why is HP-CPR important? 8

9 HP-CPR is strongly associated with improved survival and is common to communities that save 10 the most lives from cardiac arrest.xxviii xxix xxx xxxiUnfortunately, CPR usually doesn't meet 11 performance recommendations in both adult and pediatric cases.xxx xxxi xxxii xxxiii xxxiv xxxv xxxvi 12 Adoption of HP-CPR holds the promise of improved survival. 13

o What is the purpose of Part 2: HP-CPR? 14 15 The purpose of this section is to present the training, quality improvement, and leadership 16 elements needed to build a culture of excellence and transform your EMS agency into a “High 17 Performance CPR System.” 18

19

20

2. THE COMMITMENT TO ACT: CHALLENGES AND PERSPECTIVES 21

Challenges exist to implementing HP-CPR. Best practice implementation examples, combined 22 with communication and mentoring, can spur leaders to action to overcome these challenges. 23 For more details on challenges and solutions to them, please see Appendix 1 on page 73. 24

3. PERFORMANCE RECOMMENDATIONS 25

This section incorporates the latest AHA performance recommendations to address significant 26 components of adult CPR and pediatric CPR. 27

Adult Recommendations 28

HP-CPR is strongly associated with improved survival and is common to communities that save the most lives from cardiac arrest.

46

o Chest compressions should achieve proper depth, rate, recoil, and fraction. Controlled 1 ventilations should achieve proper rates and volume. Table 2 summarizes performance 2 recommendations for each of these components. It includes common errors, their possible 3 effects, and key points for providers. 4

5

Table 2: Recommendations for Adult CPR Hemodynamically & Neurologically Significant Components of Adult CPR Performance

Recommendations Common Errors & Causes

Possible Effects of Common Errors

Key Points for Providers

Chest compression depth

• At least 2 inches • No more than 2.4

inches • Approx 5 – 6 cm

• Too shallow • Too deep • Fatigue

• ↓ coronary perfusion pressure

• ↓ cerebral perfusion pressure

• Potential injuries

“Push hard, but not too hard”

Chest compression rate

• 100 – 120 per minute

• Too slow • Too fast • Fatigue

• ↑ intrathoracic pressure

• ↓ coronary perfusion pressure

• ↓ cerebral perfusion pressure

“Push fast & monitor the compression rate”

Chest recoil • Allow complete chest recoil after each compression

• Failure to allow full chest recoil

• Leaning • Fatigue

• ↑ intrathoracic pressure

• ↓ coronary perfusion pressure

• ↓ venous return

• ↓ survival

“Allow compete chest recoil”

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”Compression fraction”

• Minimize ALL interruptions to CPR

• Pauses < 10 seconds

At least 60%, but as high as possible

• Prolonged periods of no CPR: • AED analysis

& charging • Pulse checks • Changing

rescuer roles • Advanced

airway mgmt.

• Logistics around defibrillation

• Ineffective team coordination

• ↓ defibrillation success

• ↓ return of spontaneous circulation (ROSC)

• ↓ survival

“Minimize interruptions to chest compressions”

Ventilation • 10 breaths per minute

• 1 second per breath

• minimal chest rise • Tidal volume 500 –

600 ml per breath

• Excessive ventilation rate

• Prolonged ventilation duration

• Excessive tidal volume

• ↑ intrathoracic pressure

• ↓ coronary perfusion pressure

• ↓ survival

“Don’t overventilate,” offer controlled ventilations

1

2

3

4

5

6

7

Compression fraction, the percentage of time compressions are being performed during a resuscitation, should be as high as possible. The recommended 60% represents the

minimum fraction

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1

2

3

4

5

6

o Table 3: Pediatric vs. Adult CPR 7

As noted above, performance on pediatric calls will benefit from an intentional pre-arrival 8 discussion that explicitly verbalizes equipment size, defibrillation values, and medication 9 volumes. 10

11

o For more information on latest AHA guidelines, please visit the following links: 12

Rescue Breathing Instructions 13

Adult chest compression depth 14

Compression Depth 15

Differences in Pediatric and Adult CPR Pediatric Adult

Likely Arrest Etiology

Respiratory Cardiac

Rescue Breathing Instructions

(TCPR) Yes No

Sniffing Position Technique

Elevate the Shoulder Elevate the Head

Compression Depth

1/3 AP Diameter of Chest Infant (4 cm), Children (5 cm)

5 – 6 cm 2 – 2.4 in

Compressions : Ventilation

2-person rescuer 15:2 Variable by Agency

Continuous vs. 30:2

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Compression Ventilation Ratio 1

2

3

4

5

4. COMMON CPR QUALITY ISSUES 6

Recognition of CPR quality issues and their causes is an essential step toward improving 7 performance. In general, there are four common challenges: 8

o Avoiding delays, pauses, and interruptions in CPR 9 o Optimizing compression technique 10 o Managing chaos 11 o Managing the effects of airway and ventilation techniques 12

13 Avoiding delays, pauses, and interruptions in CPR 14

15 Avoiding delays in starting CPR is critical. Delays result when: 16

o EMS providers fail to recognize the patient is in cardiac arrest (often because the patient 17 is gasping, having seizure-like movements, or is “too young” to be in cardiac arrest). 18 19

o the patient must be moved (e.g., from a small bathroom to the hallway, outside the 20 bathroom, or to a location safe for providers) in order to provide HP-CPR. 21

22

With strict compliance, the patient should not be moved until ROSC has been 23 obtained unless it is impossible to provide high-quality CPR in the current 24 location. Patient movement should be kept to a minimum. 25

After CPR is started, HP-CPR minimizes pauses and interruptions. Lengthy pauses in 26 compressions occur for a number of reasons including: the need to move the patient, switching 27 chest compressors, pulse checks, rhythm analysis, defibrillation, vascular access, airway 28 management, team disorganization, lack of predetermined role coordination, and failed 29 communication. 30

31

Optimizing Compression Technique 32 33 Optimal compressions achieve target rate and depth and allow complete recoil. The following 34 can help realize them: 35

50

o Compressors should receive real-time feedback regarding compression rate, depth, and 1 recoil. In the absence of a device suitable for this purpose, the team leader must 2 provide real-time feedback to the compressor. 3

4

o The team leader should assess compression quality and direct rotation of compressors 5 at least every two minutes and/or during rhythm analysis. 6

7 o A metronome or similar rate-measuring device should always be used to help the 8

compressor maintain the target rate. There are multiple free metronome apps available 9 for personal wireless devices. 10

11

Managing Chaos 12

13 o Resuscitation usually takes place in an environment filled with complex distractions. Team 14

choreography, including strong leadership from a designated code commander with priority 15 task checklists, clear definitions of individual roles, closed-loop communication, and 16 equipment organization will help team members “stay in their lanes” and minimize chaos. 17 The following are common scene challenges along with tips for managing them. 18 19

o A good rule of thumb as you enter the scene of a cardiac arrest is to “take your own pulse 20 first.” Take a moment to ground yourself and be mindful of the critical tasks you are about 21 to perform. Think about giving that patient and his or her family your very best that day. 22 23

o If a resuscitation team can assign someone to communicate with loved-ones during the 24 resuscitation there can be positive results, regardless of the outcome.xxxvii There is no need 25 to usher family members out of the room – we now know that engaging family during a 26 resuscitation can be an important part of their understanding and healing. However, if 27 family members are disruptive or interfere with the resuscitation, efforts should be made to 28 calm them or to temporarily escort them from the space. 29 30

o Pets, poor lighting, and loud noise can distract rescue efforts. Have pets placed in another 31 room with the door closed. Turn on lights and turn off radios, televisions or other noise-32 making devices if it’s easy and helps focus. 33

34 o Re-arrest may occur en route and considerations such as time/distance from definitive care, 35

crew safety (e.g., being out of safety belts), and factors preventing High Performance CPR 36 need to be determined and addressed through department policies and training. Optimally, 37 the crew should stop the transport and re-prioritize high-quality resuscitation. This will 38 ensure delivery of ideal compressions as well as promote crew safety. Based on resource 39 availability, the role of mechanical compression devices should be considered if 40 compressions are to be performed during transport 41

42

51

Managing the effects of airway and ventilation techniques 1

Ventilation remains an essential component of CPR. The challenge is to integrate the tasks 2 of ventilation with compressions so interruptions to compressions are prevented or 3 minimized and compression quality isn’t compromised. 4

Interruptions may be unintentionally lengthened by attempts to reposition the airway, 5 reposition the mask, or synchronize ventilations to compressions. Additionally, attempts to 6 manage the airway through placement of an advanced airway may lead to lengthy 7 interruptions of chest compressions. Team distractions on the airway device can also hinder 8 the effectiveness of chest compressions. The following are tips to help integrate ventilations 9 and airway management into CPR performance. 10

11

o Clinical interventions such as endotracheal intubation, supraglottic airway 12 placement or venous access should be performed such that they do not interfere 13 with compressions. 14 15

o When effective ventilation is achieved using a non-invasive technique, consider 16 delaying or deferring placement of an invasive airway management device. 17 However, if necessary, consider placement of an advanced airway after ROSC and 18 before moving the patient. Optimal bag valve mask (BVM) ventilations are difficult 19 to ensure when moving patients. 20 21

o Preplanning should define the conditions under which repeated attempts at airway 22 device placement should occur, or if they should occur at all. High-quality 23 compressions should never be interrupted to place an advanced airway. 24 25

o Ideally, two people perform bag and mask ventilation. One person should maintain 26 an effective mask seal and appropriate airway position. The other person should 27 operate the bag with care to ensure that the proper tidal volume is delivered. 28

29

o Use a nasal pharyngeal airway (NPA) or oral pharyngeal airway (OPA) to increase 30 optimal ventilations. NPAs and OPAs can be used simultaneously. A nasal cannula 31 can also be applied during BVM ventilation to increase oxygen delivery. 32 33

o Use a timing feedback device, deliver ventilations every 10-15 compressions, or 34 have an observer time the frequency of ventilations delivered. 35 36

o Consider use of volume or pressure-limiting strategies (e.g., pediatric bag for adult 37 patient or volume or pressure limiting devices) to prevent over inflation. 38 39

Other tips and best practices useful in addressing CPR quality issues include: 40 41

52

o During manual rhythm analysis, assessment of the underlying electrical activity, 1 including shockable, organized or absence of activity, should be determined within 2 3-5 seconds. 3 4

o When a manual defibrillator is used, the device should be charged prior to stopping 5 compressions to assess the rhythm. 6

o Once the shock decision is made, CPR must be immediately resumed or the shock 7 delivered with CPR following immediately. 8 9

o During the charge sequence of the AED, the compressor should resume high-quality 10 compressions until the “deliver shock” message is given if the AED allows this 11 practice without interrupting analysis or charging sequences. This may not be 12 possible with some AED models. Some models detect motion, which can alter the 13 decision and halt the charge sequence. 14 15

o During AED rhythm or manual rhythm analysis, as well as following defibrillation, 16 the compressor should be in place with hands hovering over the chest to 17 immediately resume compressions. Prior to shock, patient clearing should be no 18 longer than 2 seconds to avoid lengthy pauses in compressions. 19 20

o One confirmation of high-quality CPR may be the presence of a pulse during 21 compressions. Assessment of a pulse during compressions just prior to a planned 22 rhythm and pulse check will allow for rapid assessment of a pulse without CPR. 23 24

o Ideally, the use of continuous EtCO2 may be used to confirm adequate ventilation, 25 assess the quality of compressions, and provide evidence of ROSC. 26 27

o Complete chest recoil is imperative. Feedback devices may can be used or 28 compressors can train with the practice of having another provider slide a piece of 29 paper under their hands at complete recoil to insure complete chest expansion. 30 31

o Providers should be vigilant about the potential for re-arrest after initial ROSC, 32 during patient packaging, or in transport. Frequent assessment/documentation of 33 continued ROSC through EtCO2, SpO2, and perfusing rhythms confirmed with a 34 pulse should be incorporated into post-ROSC protocols. Providers should discuss 35 actions to take upon re-arrest and how to best initiate high-quality CPR and effect 36 resuscitation. 37 38

o Manage the sense of futility associated with OHCA through frequent training and 39 debriefing. Identification of barriers in starting/resuming CPR, as well as sharing 40 resuscitation outcomes with data review, will promote crew buy in. Recognizing the 41

The challenge of ventilation is to integrate the tasks of ventilation with compressions so interruptions to compressions are prevented or minimized

and compression quality isn’t compromised.

53

value of one’s efforts minimizes the bias associated with perceived futility in cardiac 1 arrest resuscitation efforts. 2 3

Summary 4

Practical and well-planned actions, vigorous training, and quality-improvement metrics will lead 5 to dramatically improved resuscitation practices. Using data gathered on previously-discussed 6 performance metrics, an agency can determine where the greatest resuscitation deficits lie and 7 identify strategies for improvement. High Performance CPR should remain the primary focus as 8 a means to improve resuscitative outcomes. Optimal care involves more than just technical and 9 clinical skills, however – the best providers respond with a mindfulness that helps them do their 10 very best under whatever circumstances they may encounter. 11

12

5. TRAINING 13

So far, the document has addressed: 14

o performance recommendations for HP-CPR 15 o common CPR quality issues and tips for eliminating or reducing them. 16

We now turn to training. As noted previously, HP-CPR is the foundation of all successful 17 resuscitation and is the most important therapy in treating OHCA. Other interventions, such 18 as advanced airway management and drug administration, should never interrupt CPR or 19 compromise chest compression quality. 20

HP-CPR is not complex, but it isn’t easy. Professional rescuers may think they’re achieving 21 recommended performance measures, but often they are not. Proper training is the foundation 22 for success and should be mostly “hands-on” and measured for quality. Cognitive training 23 should be no more than 20% of the total training time. Retraining should occur at least every 6 24 months, but more frequent retraining is better. 25

The pages that follow summarize the things you’ll need to keep in mind and have on hand. 26

27

Preparation 28

Class Time 29

• At least 4 hours 30

Audience 31

• EMTs 32 • Paramedics 33 • Training Officers 34 • Nurses 35 • Respiratory Therapists 36

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• Nurse Practitioners 1 • Physician Assistants 2 • Agency Medical Directors 3 • Industry stakeholders 4

5

What You’ll Need 6

The training environment is very important in promoting mastery. Here’s a list of things you’ll need to 7 optimize the learning experience: 8

• Class agenda 9 • Sign-in sheet 10 • Name badges 11 • Classroom with plenty of open floor space 12 • Chairs 13 • 1 manikin (CPR quality feedback or high fidelity 14

preferred) for every 6 students 15 • Defibrillators (or AEDs) 16 • Defibrillator training pads (use the same equipment 17

you would use on a call whenever possible) 18 • Electrical outlets 19 • Computer 20 • PowerPoint projector (or TV monitor) 21 • Snacks 22 • Evaluation forms 23

24

25

26

27

Resuscitation Pods 28

• Each “pod” consists of chairs in semi-circle around a 29 manikin 30

• Each pod also needs a defibrillator (or AED) with 31 training pads and a bag-valve-mask (BVM) 32

• Each resuscitation pod should have a “pod 33 instructor” (PI) 34

• Maximum student-to-manikin ratio of 6:1 35

Figure 1. Resuscitation pod set up for 5 students and

1 pod instructor (PI)

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• High fidelity manikins are preferred; monitor/defib/AED with CPR feedback also preferred 1

Classroom Setup 2

• The ideal HP-CPR classroom is modular and scalable 3 • The class is conducted by a lead instructor who 4

coordinates content delivery and manages time 5 • If there are a sufficient number of manikins, 6

defibrillators, BVMs, and pod instructors, a single 7 classroom might have 5 or 6 pods (or even 10 or more.) 8

• Remove the tables! There should be no physical 9 barriers between the students and the manikin 10

• Use a single metronome so the class doesn’t get 11 confused 12

13

Coordination 14

• One of our main objectives is to break down HP-CPR 15 into its component skills (e.g., compression skills) and 16 master each. Then we move on to the next skill. 17 18

• The PI can assign individual roles based on the student’s chair number. For example, “In this 19 evolution, #1 will be monitor, #2 will be chest compressions, and #3 will be airway” 20 21

• When the evolution is complete, the students return to their assigned chairs so the Lead 22 Instructor can see that the pod is ready for the next evolution 23

24

25

Circle of Learning 26

The High-Performance CPR Circle of Learning illustrates that 27 High-Performance CPR is a continuous process intended to 28 transform actual performance during emergencies. 29

• Starts in the classroom but meant for the 30 street/hospital 31

• Designed to give professional rescuers the skills, 32 knowledge, and ability to work together at a very 33 high level. 34

35

Figure 3. High Performance CPR “Circle of Learning”

Figure 2. Classroom set up with 4 resuscitation pods (20 students)

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1

Know the Recommendations 2

Evidence-based guidelines (see Tables 2 and 3) tell us what to do. High quality training shows us how to 3 do it. The very best training includes the “why”. 4

Adult learners like to know the reason they are being asked to perform in a particular way. Professional 5 rescuers want to do a good job. If they’re compressing too fast, not allowing full recoil, or over-6 ventilating, it’s not intentional. 7

Present an inspiring survivor story from your own EMS 8 system. This isn’t about statistics. It’s about human lives! 9

Balance explanation of the critical concepts of HP-CPR 10 against training time. GOAL: Consistently excellent hands-on 11 performance. 12

• At least 80% of High Performance CPR training 13 should be hands on. 14

• At the end of the day, High Performance CPR is 15 something that happens on your hands and knees! 16 (For this reason, it’s a good idea to have padding to 17 kneel on when you train). 18

19

20

21

22

23

24

Compression Skills 25

A good chest compression has 3 important qualities: rate, depth, and recoil. Survival depends on 26 maximizing effectiveness of all three. 27

• Rate: 28

100-120 29

30

31

Figure 5. Compression Skills

The relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012;125(24):3004–3012

Figure 4. Cognitive Learning

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1

2

3

• Depth: 2.0-2.4 in (5-6 cm/50-60 mm) 4

5

6

7

8

9

10

• Recoil 11

(Avoid Leaning) 12

13

14

15

16

17

18

In addition, compression fraction (the percentage of time compressions are being performed during a 19 resuscitation) impacts survival – that’s why we want to keep interruptions to a minimum. Compressions 20 should be performed at least 60% of the time, but the higher the fraction, the better. 21

For more on compression skills, please see Appendix 2, page 79 22

23

Ventilation Skills 24

What is the Role of Chest Compression Depth during Out-of-Hospital Cardiac Arrest Resuscitation? Crit Care Med 2012 Apr;40(4):1192-1198

The prevalence of chest compression leaning during in-hospital cardiopulmonary resuscitation. Resuscitation 2011 Aug; 82(8):1019-1024

One way to ensure full recoil is to allow the heel of your hand to come all the way off the chest during the upstroke. You should be able to swipe a credit card between the heel of your hand and the chest.

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Ventilations should be controlled. 1

Keep these things in mind: 2

• Don’t squeeze the bag too often 3 • Squeeze just enough for chest rise 4 • Allow full release of the bag 5 • Ideally, two people manage ventilation. One assures 6

a proper seal over the mouth and nose. The other 7 provides controlled ventilations. 8

9

Why are uncontrolled ventilations bad? 10

Positive pressure ventilations increase intrathoracic 11 pressure, which decreases blood return to the heart, which 12 lowers cardiac output during CPR. 13

Note: Some BVMs are “smart bags” that limit flow and may prevent excessive airway pressures, volume, 14 and rate. Use of a timing light for ventilations may help also. 15

For more on ventilation skills, please see Appendix 3, page 79. 16

Optimize Teamwork 17

Once each individual has learned how to perform 18 consistently excellent chest compressions and perfect 19 ventilations it’s time to combine these skills and work 20 together as a team. 21

Keep in mind that standardized equipment placement 22 during a resuscitation makes consistent performance much 23 easier. 24

25

Before You Get There 26

Everyone needs to know their individual assignment before 27 they arrive on scene. They also need to know the shared 28 priorities and goals that make up team “choreography.” 29 Knowing this helps to avoid duplication and prevents gaps in 30 the performance of critical tasks. Some systems may find that an assignment given at the beginning of 31 the shift is best (“today you are compressor 1”). Other systems may prefer other methods (e.g., “‘Left 32 Rear Seat’” is always compressor 1”). By whatever means, everyone needs to know their position and 33 responsibilities when they arrive. 34

Positions and responsibilities will vary from one agency to another. Here’s one way of breaking them 35 down: 36

Figure 6. Ventilation Skills

Figure 7. Optimize Teamwork

59

Positions: 1

• Position 1: Monitor / AED 2

• Position 2: Chest Compressions 3

• Position 3: Airway 4

• Position 4: Timekeeper / Assistant 5

Responsibilities: 6

Position 1 7

• Places monitor at 45-degree angle to left shoulder (monitor can be set back a few feet from 8 working area) 9

• Checks pulse and announces “no pulse, begin CPR” 10

• Attaches capnography circuit to monitor 11

• Extends pads and coordinates placement with rescuer on chest compressions 12

• Changes monitor to pediatric mode if applicable 13

• When appropriate pre-charges the monitor and manages peri-shock pause 14

Position 2 15

• “Hovers” during pulse check 16

• Performs CPR at correct rate, depth, and recoil 17

• Accepts feedback from crew members about CPR quality 18

• Coordinates pad placement with rescuer on monitor 19

• Counts out loud “13, 14, 15″ or “28, 29, 30” to prompt rescuer on airway to give breaths 20

• Waits two full seconds for airway position to give breaths and continues compressions 21

• Helps keep track of 2-minute cycle 22

• When Monitor/AED position announces “stop CPR” at the beginning of the peri-shock pause this 23 rescuer clears out of the way 24

25

Position 3 26

• Announces “I’ve got airway” 27

• Selects the correct sized BVM and attaches capnography between mask and bag 28

• Announces “ready for 15:2″ or “ready for 30:2” 29

60

• Reminds rescuer on compressions to count last three 1

• Ventilations are given correctly (just enough to produce chest rise with full release between 2 ventilations) 3

• Manages the patient’s airway as necessary 4

Position 4 5

• Starts metronome and acts as timekeeper 6

• Turns on oxygen and hooks up BVM to oxygen at 15 LPM 7

• Selects correct sized OPA for the rescuer on the airway 8

• Deploys and tests suction unit 9

• If pediatric, takes out Handtevy book and determines child’s age 10

• Reminds rescuer on monitor to pre-charge the capacitor at 1:45 into the cycle 11

12

When You Get There 13

There are a few things to size up when you arrive: 14

o Is the scene safe for the team? 15 16

o Is anyone doing CPR? 17 18

o If yes, your team leader should judge the CPR quality and immediately relieve the 19 person doing CPR. The team leader let the team know the CPR quality and enter it into 20 the report because CPR quality can impact decisions about how long to resuscitate and 21 can affect the hospital providers’ early impression of the chance the patient survives. 22 23

o Is the patient in cardiac arrest? 24 25

o Initial patient assessment should take no more than 10 seconds. Remember, “if there’s 26 doubt, there is no doubt” – if you’re not sure whether there’s a pulse, start CPR. 27

28 o Don’t get fooled by agonal breathing. We sometimes mistake it for signs of life and this 29

delays CPR. Your training should include how to recognize agonal breathing. Here are 30 some examples of what it can sound like: 31

32

Agonal 1.wav

Agonal 2.mp3

Agonal 3.mp3

33

(Editor’s Note: link to sample audio file will be included in final report) 34

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Here are some examples of how 9-1-1 callers describe it: 1

2

Agonal described

1.wav Agonals described

2.wav Agonals described

3.mp3 3

(Editor’s Note: link to sample audio file will be included in final report) 4 5

o Is there enough room for the crew? 6 o We need enough space to do HP-CPR. You may need to move the patient or clear 7

furniture. Remember, however: as a rule, patients should not be moved until ROSC has 8 been obtained. Only move the patient if necessary! 9

10 o If there is apparent trauma, is it really responsible? 11

12 o Be suspicious of “trauma” cardiac arrests. If an event seems unlikely to cause cardiac 13

arrest (a minor motor vehicle accident, for example), it may have resulted from cardiac 14 arrest. If in doubt, there is no doubt – start resuscitation. 15 16

o If resources allow, emphasize early application of defibrillator pads. If good CPR is in progress 17 when you arrive, consider early rhythm check. 18

19

Types of CPR Delivery: 20

Standard CPR 21

The most common method of ventilation during cardiac arrest is to deliver 2 breaths for every 30 chest 22 compressions, which is referred to as “30 to 2”. 23

Without proper training it is not uncommon for crews to pause 5 or 6 seconds to provide 2 breaths! 24 Manikins are often hard to ventilate – the chest doesn’t rise the way we think it should, for example. 25 This can lead us to deliver too much air and waste precious 26 time in real life. With HP-CPR the delay for ventilations 27 should be only about 3 seconds: one second in, one second 28 passive expiration, one second in. Then continue with 30 29 compressions. 30

The rescuer on airway is responsible for delivering the 31 breaths during this short pause. The rescuer on chest 32 compressions should start again after 3 seconds whether 33 the breaths have gone in or not. 34

This helps prevent the precipitous decline in coronary and 35 cerebral perfusion pressure associated with excessive 36

Consider holding the BVM by the end or using a

thumb and 2 or 3 fingers to ventilate. This is sometimes called “pinky-up” or “princess”

ventilations.

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delays. Continue holding the mask on the face to deliver passive oxygenation during compressions. 1

2

BLS Continuous 3

Some systems provide continuous chest compressions and interpose one small breath every 10th 4 compression. This requires practice but can be done without an advanced airway in place. 5

6

Passive Oxygenation 7

Some systems perform 3 cycles (some perform more) of continuous chest compressions with passive 8 oxygen administration for adult, witnessed cardiac arrest. This is sometimes referred to as the Minimally 9 Interrupted Cardiac Resuscitation (MICR) protocol. For a sample MICR protocol, please see Appendix 4, 10 page 80. 11

Regardless of which compression/ventilation strategy is used the same advice applies – be the best you 12 can be at that method! 13

14

Defibrillation 15

Once students can perform chest compressions and ventilations together as a team, defibrillation is 16 added. 17

There are logical reasons for resuscitation teams to interrupt CPR, including to perform rhythm checks, 18 to defibrillate, or to switch out the rescuer on chest compressions. 19

We should train to combine these interruptions into the same (short!) interval to minimize pauses and 20 delays in CPR. 21

The term “perishock pause” is used to measure how long we interrupt CPR to perform defibrillation. 22 Keep the hands-off-chest time during rhythm check/compressor change to 10 seconds or less – highly 23 functioning crews can limit this to 2 or 3 seconds. 24

Perishock pause has two components. 25

• The pre-shock pause 26 • The post-shock pause 27

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1

2

One of the ways we can minimize hands-off time is to pre-charge the defibrillator at the 1:45 mark of 3 each cycle. The compressor should call out time (from the monitor) to keep the team in sync. A crew 4 member should locate the compression pulse in the groin and maintain contact with that point when 5 compressions are paused. 6

Chest compressions should not be interrupted during the pre-charge. However, it should alert the team 7 that it’s time to switch out the rescuer on chest compressions. For more on defibrillation, please see 8 Appendix 5, page 80. 9

10

Scenario-based simulations 11

Simulation training helps teams and individuals hone their proficiency in realistic conditions. 12 Providers must train in teams with other providers so that they can function as a unit, just as 13 they must do in real life resuscitation attempts. The amount of training time varies based on 14 rescuers’ backgrounds, skill levels, and the frequency with which they perform CPR. 15

16

17

18

Here are some scenarios you can use in training: 19

20

1 - WITNESSED WITH NO BYSTANDER CPR 21

Tip

Find the femoral pulse during compressions – your fingers will be in the perfect place to assess whether there’s a pulse during the

perishock pause

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67-year-old male collapses while playing tennis. He is unconscious with gasping respirations. Skin color is 1 gray-blue. On EMS arrival the patient is found in the recovery position. Initial assessment reveals no 2 pulse. 3

4

2 - WITNESSED WITH BYSTANDER CPR 5

21-year-old college soccer player collapses on the field and is determined to have suffered sudden 6 cardiac arrest by the athletic trainer. Someone has reportedly been sent to the school to retrieve the 7 AED but it has not yet arrived. High quality CPR is being performed by the athletic trainer and an off-8 duty nurse. 9

10

3 - UNWITNESSED 11

38-year-old female found by her roommate unconscious in the bathroom. She is reportedly a recovering 12 addict. The scene is safe. Bystander CPR is being performed by a law enforcement officer at the time of 13 EMS arrival. It is a small bathroom. 14

15

4 - PEDIATRIC 16

5-year-old male discovered missing by parents. Found floating in back yard pool. Child is pulled out of 17 the swimming pool. The patient's father is performing CPR on EMS arrival. The mother is screaming. The 18 hospital is 5 minutes away. 19

20

5 - SPECIAL SITUATION 21

58-year-old female is a restrained operator of a motor vehicle involved in a minor motor vehicle 22 collision. She is unconscious and slumped forward. Skin color is blue. The scene is safe. A bystander 23

placed the vehicle in park and turned off the ignition. The patient does not appear to be breathing. 24

25

26

Measure & Improve Performance 27

.

Each member of the team should function in every role until mastery. Consistently excellent CPR delivery is what High Performance CPR is all about.

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High Performance CPR is about improving patient outcomes. 1 Once your team is proficient in HP-CPR practice, they must 2 start to use the skills during actual emergencies. 3

Through team debriefings, analysis of CPR performance with 4 defibrillator data downloads (software that helps measure 5 things like CPR fraction and perishock pauses), you can 6 identify opportunities for improvement that can in turn be 7 incorporated into the next iteration of your HP-CPR class. 8 The process never ends! 9

Additional Information 10

Identifying Return of Spontaneous Circulation (ROSC) 11

• Sudden rise in ETCO2 12 • Organized rhythm on the monitor 13 • Improvement in skin color 14 • Consistent SpO2 pleth waveform 15 • Patient movement or respiratory effort 16 • Confirmed with a pulse check 17

Post-Resuscitation Care 18

• Anticipate re-arrest. An orderly exit from the scene may allow more efficient treatment if re-19 arrest occurs. 20

• Anticipate BP drop: Know strategy to treatment with BP goals using fluid or pressors 21 • Minimize lung injury: elevate head of bed to avoid aspiration, limit tidal volumes, place 22

nasogastric tube as necessary 23 • Use sedation protocol if patient is fighting tube 24 • Attach pulse oximetry 25 • Obtain a full set of vital signs including temperature 26 • Acquire a 12-lead ECG 27 • Rapid transport and activate cardiac cath lab if 12-lead ECG shows STEMI 28 • Turn on VF/VT alarm 29 • Assemble an appropriate transport team (at least 3 in back of ambulance) 30 • Transport the patient to an appropriate medical facility 31 • Engage social work/chaplain for the patient/family at the hospital 32

Transitioning to Mechanical CPR 33

• Have a plan! 34 • Measure application time 35 • Practice, practice, practice, and practice some more. Crews have to be well versed in 36

mechanical CPR device application. Applying these devices can eat up a significant amount of 37 time before we realize it. Have someone count out loud and keep the hands-off-chest time for 38 application of the device to 10 seconds or less. 39

Figure 7. Clinical Practice

66

• For more on the transition to Mechanical CPR, please see Appendix 7, page 81. 1 2 6. ACHIEVING AN HP-CPR CULTURE OF EXCELLENCE 3

4 We described the importance of leadership, accountability, and continuous quality 5 improvement in creating a “culture of excellence” on page 3. In this section, we note: 6

7 o how EMS leaders can build necessary bridges between stakeholders across the 8

Chain of Survival 9 o specific elements of EMS CQI 10 o additional steps EMS agencies can take toward a culture of excellence. 11

12 13

Building Bridges 14

EMS leaders can move toward a culture of excellence by connecting essential players across 15 the spectrum of OHCA care. They can foster accountability and cooperation between their 16 agencies, PSAPs and hospitals by convening review committees to evaluate OHCA events, 17 outcomes, and opportunities to improve care. The committees can help celebrate successes 18 and advise executive stakeholders of unmet needs. Committee members should include: 19 20

o EMS agency operational (paramedic, EMS Lieutenant, etc) representative 21 o EMS agency CQI representative 22 o PSAP operational telecommunicator representative 23 o PSAP CQI representative 24 o Medical Director/Oversight representative 25 o Hospital Emergency Room operational (RN, paramedic) representative 26 o Hospital CQI representative 27

Leaders can also convene executive committees to oversee policy resource direction. An 28 executive committee could include: 29

o Medical Director/Oversight executive 30 o EMS agency CQI representative 31 o EMS Chief 32 o PSAP CQI representative 33 o PSAP Director 34 o Emergency Room Clinical Manager 35 o Hospital CQI representative 36

37 The PSAP CQI and EMS CQI representatives should participate in both the review and 38 executive committees. This not only gives executives an opportunity to learn from the 39 operational perspective; it also indirectly provides a sense of empowerment and a voice to 40 the “front line” 9-1-1 and EMS personnel. The executive committee can assess 41

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recommendations from the review committee, approve policy, and provide resources to 1 improve OHCA care and outcomes. 2

3 Specific Elements of CQI 4

5 CQI is, by definition, ongoing and devoted to improvement. It can take the form of 6

(1) standardized reporting on overall staff performance that highlights collective 7 strengths and weakness and 8

(2) debriefings where personnel discuss the events they participate in and see how their 9 personal performance compares with the standards cited in Section 2. 10

11 12 13 14 15 16 17 18 19 20 21 22 23 24

25 26 27 28 Figure: A model for CQI. Data collection, reporting and feedback to individual 29 providers can help agencies refine their regular trainings in an ongoing effort to 30 enhance OHCA care. 31 32 o Standardized reporting 33

Measuring and reporting health outcomes are central to assessing the quality of 34 care for all conditions and cardiac arrest is no different. It is widely held that “We 35 cannot improve something we do not measure.” Measurement sheds light on 36 quality of care and can inspire improvements in both process and outcomes. 37

Many EMS functions are hard to measure accurately. Cardiac resuscitation, 38 however, and particularly resuscitation of witnessed OHCA patients in shockable 39 rhythms when EMS arrive, is relatively easy to measure. 40

Data Collecti

Feedback (individu

Reporting/

Training/ Retrainin

68

Data collection tools that can be used to generate report on overall staff 1 performance can be found here. 2

A data dictionary and standard template for patient outcome reports can be found 3 here. 4

5

o Debriefing 6

Allowing personnel to share their experience after resuscitation attempts can 7 provide insights that improve CPR and can help rescuers better process these 8 events. OHCA case review among team members, then, provides the platform for 9 constructive and non-punitive communication that can identify challenges and/or 10 best practices and in turn inform future efforts. 11

In this setting, debriefing refers to a dedicated dialogue after a cardiac arrest event 12 in which individual actions and overall team performance are openly reviewed. This 13 technique can be extremely helpful for realizing high-performance CPR. Debriefing 14 is most effective if performed while the resuscitation is fresh in the rescuer’s 15 thoughts. 16

There are two types of resuscitation debriefing techniques: “hot” debriefing and 17 “cold” debriefing. 18

19

“Hot” Debriefing 20

Hot debriefing and entails a collective discussion by team members immediately 21 following the resuscitation attempt. Usually, objective CPR performance data are 22 not readily available, so the team focuses on their overall reaction to the event and 23 what went well and what could have been improved. This approach is usually easily 24 adaptable for OHCA resuscitations, as it can entail a simple “group huddle” among 25 providers. This style of “hot” debriefing is useful for teamwork. However, without 26 actual CPR process data (e.g., chest compression depth, rate, pauses, etc.), it is 27 unlikely to have a significant impact on CPR performance itself. 28

29

“Cold” Debriefing 30

Cold debriefing occurs a few days after the resuscitation attempt. It has some 31 benefits over hot debriefing. First, as get-togethers take place days (ideally a few 32 days but not weeks later) after the resuscitation attempt, CPR performance data can 33 be downloaded, evaluated and joined into the debriefing session. This pause 34 between event and debriefing also gives providers the opportunity to reflect on the 35 resuscitation event. Secondly, in contrast to hot debriefing, cold debriefing can be 36 made accessible to all team members, thus permitting providers to learn from each 37 other in a more structured and regularly scheduled debriefing session. 38

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The debriefing may incorporate the defibrillator recording given its objective 1 assessment of CPR performance. Many of the defibrillator manufacturers provide 2 software that enable objective assessment of some CPR metrics. These metrics can 3 be provided in a static summary manner or presented in a real-time manner by 4 “playing” the defibrillator recording, enabling the crew to observe the case second-5 by-second. 6

7

Additional steps agencies can take toward a culture of excellence 8

9 o Commit resources to create or use existing OHCA registries and measure OHCA 10

care 11 12

o Meet with frontline EMS providers and groups to explain goals and get feedback 13 14

o Meet with affiliated organizations (telecommunications, hospitals, lay advocacy 15 groups) 16 17

o Support learning opportunities involving resuscitation (internal focus on 18 resuscitation/ attending Resuscitation Academies) 19 20

o Commit to a training schedule (regularly practice CPR) 21 22

o Create and maintain a performance dashboard (key indicator report on an 23 ongoing/ cyclical basis) 24 25

o Share (Annual) Performance Report with external and internal stakeholders 26 27

o Acknowledge success (for example, organizing survivor celebrations) 28 29

o Support resilience (chaplain program, mental health services for personnel) 30

31

32

33

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APPENDICES 1

2

Appendix 1: Barriers to HP CPR Implementation 3

The Science - Implementation Gap 4

A large gap exists between knowledge of the science of CPR quality and the ideal implementation, 5 leading to large numbers of preventable deaths from cardiac arrest. Historically, attention has 6 appropriately focused on addressing the barriers to the technical skill and application of HP CPR. The 7 barriers in moving from knowledge to implementing scientific guidelines of CPR and best practices 8 extend beyond a focus on improvement of CPR skills alone. Effective implementation of CPR quality 9 improvement initiatives require broader strategies that address organizational, operational, cultural and 10 leadership barriers.xxxviii These barriers are clearly intertwined as are the possible approaches to 11 overcome these barriers. 12

Eisenberg et al defined ten actions required for implementing cardiac arrest survival improvements 13 within a community. These implementation actions include: 14

• Select program or programs to implement 15 • Form a team or advisory board 16 • Determine how to make it happen in your community 17 • Set specific goals 18 • Establish performance standards 19 • Achieve buy-in from agency personnel 20 • Consider a pilot program 21 • Communicate progress within the agency 22 • Communicate with the public and EMS personnel 23 • Support, advocate, celebratexxxix 24

Barriers to Implementation 25

Several of these steps directly address common organizational, leadership and cultural barriers to 26 implementing high performance CPR improvement strategies within an EMS organization.xl Such 27 barriers are not exclusive to EMS. Implementation barriers include: 28

• Leadership 29

o Misalignment of CPR quality with organizational vision, mission, values and goals 30 The organization’s strategic plan does not clearly lead staff towards a vision of 31 excellence and quality. 32

o A top-down only culture 33 Decisions are made by leadership with little to no inclusion, input or influence from those 34

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staff closest to the work being improved. This is in contrast to the high reliability 1 organization principle of deference to expertise. 2

o Lack of engagement and support by the organization’s leadership and medical director 3 Without leadership support and active involvement, staff may not see value in engaging 4 in improvement efforts believing instead that such efforts will simply meet resistance. 5

o Lack of receptivity toward changes in practices 6 Leadership may not recognize or see the need for HP CPR or CPR improvement at all. 7 They may believe current CPR performance is adequate or superior. 8

o Lack of a clearly defined plan for improvement 9 Leaders may desire to improve CPR performance but do not utilize staff and all available 10 resources to create a plan for improvement. 11

o Ineffective or absent communication and feedback to field staff 12 Most EMS providers desire feedback about their performance but fail to receive it. When 13 improvement plans are created, they may not be openly communicated to staff who will 14 then be responsible for implementing. 15

• Cultural 16

o A blame focused performance improvement culture 17 An individualistic culture to improving performance focuses on blame. In turn, staff are 18 fearful leading to a lack of desire to engage in improvement efforts or share ideas. 19

o Focus on individual performance causes only rather than including systems and teams 20 An individualistic culture fails to consider the impact of teamwork and how other factors 21 outside of the individual’s control impact CPR performance. 22

o Lack of accountability 23 Focusing on blame rather than encouraging accountability creates an emotional toll on 24 staff. Without accountability, staff and systems lack awareness of CPR performance. 25 Accountability acknowledges human fallibility and seeks to build respect, trust and a 26 desire to meet performance expectations. 27

o Lack of engagement of field staff in improvement efforts 28 Without a bottom-up approach, the full value of employee input, engagement and 29 acceptance is not reached. If staff are not actively engaged in the process of CPR 30 improvement, they are less likely to champion defined improvement efforts or to accept 31 them at all. 32

o Resistance to change 33 Staff and management expected to simply accept change as dictated to them are less 34 likely to accept or promote the changes. The human aspect of change often begins with 35 resistance and EMS personnel are not at all immune to such feelings of resistance. 36

o Lack of recognition of potential harm caused by suboptimal CPR quality 37 Culture is local and thus uniquely develops locally. Staff may not see the value of CPR 38 quality or may not recognize the potential harm caused by suboptimal CPR resulting in 39 the development of a local cultural belief that CPR quality is adequate and not an 40 important opportunity for improvement. 41

42

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• Operational & Organizational 1

o Costs of training, staff, equipment and/or devices 2 Organizations may attempt to implement many improvements and changes at once 3 requiring significant financial and human resources, thus risking failure. 4

o Lack of staff resources for training and performance review 5 Staff resource limitations are common in EMS organizations. Alternative approaches to 6 training and case reviews may not be adequately explored. 7

o Competing priorities and/or limited capacities 8 Leadership and staff may feel overwhelmed with the increasing number of priorities 9 facing the organization. Reimbursement, personnel shortages, fatigue, personal safety 10 and other clinical quality concerns are among the important and competing priorities. 11 This risks an HP CPR program not being implemented. 12

o Lack of investment in performance measurement, monitoring and feedback 13 mechanisms 14 Organizations may not adequately explore methods for real-time and post event 15 performance measurement and feedback. 16

o Attempt to address all CPR performance weaknesses at once 17 In addition to taxing limited resources, this approach may fail to address the impact of 18 change in one performance aspect on another aspect of resuscitation performance. 19 Large scale implementation is much more challenging than smaller scale improvements 20 and at more risk for failed implementation. 21

22 o Solutions to these challenges 23

24 o CPR Implementation 25

26 o Tremendous opportunities to maximize survival in local communities occur through 27

engagement of the leadership of the local EMS agency and the EMS workers (EMTs and 28 paramedics) who provide care at the patient’s side. The endorsement by an agency’s 29 organizational culture of high performance CPR implementation is critical in moving 30 from evidence to action. A recent important success changing the culture of healthcare 31 occurred in the campaign to eliminate central-line associated blood stream infections.xli 32 Pronovost analyzed the impact of healthcare culture on implementation identifying best 33 practices as well as challenges. Best practices included: 34 35 focusing on teamwork 36 establishing valid performance measures 37 summarizing best evidence into checklists 38 providing clinicians with continuous feedback on established measures 39

40 He reported that all healthcare culture is local. Similarly, all EMS care is local; 41 important gains can be accomplished by achieving buy-in from the boots-on-42 the-ground EMS providers.xlii 43 44

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1 2

o Poor CPR a Preventable Harm 3 4

“Poor quality CPR should be considered a preventable harm.”xliii One important solution 5 addressing the preventable harm is implementing High Performance CPR in an EMS 6 organization. Successful teaching changes behavior and represents the true definition of 7 learning; in order to change behavior throughout the EMS agency, a best practice is to 8 engage the culture of the organization. The publication, Strategy for a National EMS 9 Culture of Safety, identifies “Just Culture” as a solution to the cultural resistance to 10 implementation. Elements of Just Culture include an organizational environment that 11 sets expectations that individuals report mistakes which then evaluates risks leading to 12 errors. The focus on risk, rather than negative outcomes, while addressing system 13 factors, allows modification of these factors in a collaborative way, without blame or 14 punishment. Similarly, this culture supports sharing with the worker valid performance 15 data based upon established measures; this represents an additional way that the 16 leadership can show support and respect for the care delivered by the EMS worker. 17

18 19

o Bottom-up Implementation 20 21

There is an opportunity for improvement by working within the culture of the EMS 22 organization. One promising method of implementation of High Performance CPR 23 involves beginning the change from the “bottom up,” giving the information to select 24 EMS workers, and having them adapt the techniques to their team work processes. In 25 this way, the workers have buy-in/ownership of the implementation. Optimal selection 26 of the company or crew best able to undertake this pilot implementation can hinge, in 27 part, to how much of an “early adopter” culture exists in the crew. It is likely that the 28 crew selected have previously piloted rollouts of other new policies or equipment in 29 their department. 30 31

Similar to the hospital implementation of reducing infections from central lines, 32 adapting the hospital implementation process steps to work for a department intent on 33 rolling this best practice out across a shift and eventually the entire department. At each 34 phase of the rollout, crews pilot the HP-CPR. When the incremental pilot 35 implementation delivers success, it develops more workers supporting the culture of 36 change. Gradually, more supporters replace disbelievers until the believers outnumber 37 those who do not believe in the program. When a critical mass of believers exists in a 38 department, outnumbering the non-believers, change in the culture can occur. 39 40

An example/potential impact of how this cultural shift can reverse expectations is 41 evident when the prevailing cultural attitude is despair and a feeling that the EMS 42 workers, though joining the profession to help and to save lives, are not making an 43 impact in their care of cardiac arrest. Following the pilot and culture change, their 44

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attitude is ‘flipped,’ when evaluating that subset of cardiac arrest patients with a 1 witnessed arrest and a shockable rhythm, now they believe they should accomplish 2 return of circulation for all patients. In practice, after successful implementation, it is 3 not unusual for return of spontaneous circulation rates to approach 60-65%. Thus, 4 success occurs in the majority and they focus on the approximate 1/3 for whom they did 5 not succeed. When they do not accomplish ROSC they review their performance 6 feedback on that case, praising what they did well, but being very single-minded when 7 evaluating what they could improve next time to succeed at saving a life. 8

9 10

11 o Top-Down Implementation 12

13 o To pilot a bottom-up implementation for high performance CPR has the benefit of 14

engaging the workers and recruiting their support for the change. There are clear 15 benefits as well, in support for the pilot implementation from the leadership above.xliv 16 This can occur in many ways and at different times. Most simply, communication and 17 vision from the top, in announcing support from leadership for the pilot can be crucial in 18 setting the pilot up to succeed. Another model that can succeed synergistically is, 19 following buy-in and engagement from the pilot crew, sharing the HP-CPR protocol from 20 the top down while extolling the benefit of the field contribution and ‘boots on the 21 ground’ rollout. An additional method, if the HP-CPR protocol is already in place, can 22 occur after success of the pilot. In this situation, despite a critical mass of personnel who 23 support the change, there may still exists a quarter to as much as a third of the agency 24 that have yet to accept the change. In this situation, release of a HP-CPR order can help 25 complete and cement the change. Once the collaborative order is out, supported by the 26 majority of the department, field level managers and supervisors can engage those 27 workers not implementing the pilot by emphasizing that now there is a requirement, an 28 order, to implement. Much larger implementations are also possible, from a state or 29 national level.xlv In these cases, leadership and support from the top, preceding pilot 30 rollout, for example, setting a strategy, gaining approval of elected officials, publicizing 31 implementation through social media and publishing a HP-CPR protocol to ensure 32 consistency in local rollouts are crucial to success. 33

Action Steps for Overcoming Barriers 34

Essential to the successful implementation of high performance CPR initiatives are practical actions 35 overcoming the above listed barriers. Although all are vital, these actions may be implemented in 36 phases particularly when an organization has limited financial and/or staffing resources. 37

Leadership 38

The active involvement of leadership in quality improvement efforts encourages involvement at other 39 levels of the organization.xlviThough a top-down implementation alone is not necessarily ideal, the 40 organization’s leadership including the medical director should: 41

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1. Foster openness to quality improvement and change through a culture of respect and inclusion 1 (ACHE, 2017) 2

2. Ensure clinical quality including CPR quality initiatives are both aligned with and a part of the 3 organization’s vision, mission, values and goals. xlvii 4

3. Support and demonstrate active engagement in CPR quality improvement initiatives at all levels 5 of leadership, management and staff. 6

4. Formulate a clear plan for implementing, monitoring and improving HP CPR within the 7 organization consistent with Eisenberg’s ten steps.xl 8

5. Ensure inclusion of all levels of staff in planning and implementing CPR quality improvements.xlviii 9 6. Inspire and encourage both top-down and bottom-up approaches to defining performance 10

improvement opportunities and creating improvement solutions. Seek to incorporate the high 11 reliability principle of deference to expertise by fully utilizing input and ideas from staff closest 12 to the resuscitation work. 13

7. Establish effective communication and feedback mechanisms and share CPR quality 14 improvement efforts and results with all levels of the organization. 15

16

Cultural 17

1. Consider adopting a just culture or learning culture while seeking to eliminate blame. 18 2. Adopt an improvement culture that focuses on systems and teams rather than solely on 19

individuals (Pronovost, Peter J., 2010). 20 3. Seek accountability by defining performance expectations, monitoring performance and sharing 21

actual CPR performance with staff for the purposes of improvement rather than finding fault. 22 4. Engage staff closest to the field resuscitation work in the development and testing of 23

improvement initiatives. 24 5. Foster a culture that recognizes suboptimal CPR quality as preventable harm to patients. 25

Through education, communication and celebration of successes, demonstrate the value of CPR 26 quality. 27

28

Operational & Organizational 29

1. Create a plan that utilizes a phased-in approach of multiple improvements over time. 30 2. Prioritize the organization’s priorities in a manner that is consistent with the strategic plan and 31

illustrates to leadership, management and staff the value placed on CPR quality improvement. 32 3. Implement in small increments (baby 33

steps) to both minimize the initial financial 34 impact and the burden on staff. Utilize a 35 PDCA/PDSA approach to evaluate how well 36 a small change or set of changes improves 37 performance. 38

4. Utilize small change improvements to 39 create champions who will then spread the 40 message of success to others. 41

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5. Identify simply, low cost solutions to measuring, monitoring and improving CPR performance. 1 For example, small, low cost, battery operated metronomes may be easily found at music 2 stores. Alternatively, a metronome app can be downloaded to any smartphone and used to 3 boost team performance by helping EMT’s find and stay in the “sweet spot” for survival when 4 delivering chest compressions. 5

6. Plan for larger scale CPR quality measurement, monitoring and feedback devices in future 6 budgets rather than attempting to implement all at once when financial resources are limited. 7 For example, consider incorporating CPR performance devices in future capital purchases of 8 AEDs or similar cardiac monitoring devices. 9

10

Appendix 2: Chest Compressions 11

The team approach trains each team member to recognize the “primacy” of the compressor. High 12 quality compressions are the most important initial intervention. The team should be encouraged to call 13 out and correct any observed deficiency. CPR must be performed to the highest standard with 14 recognition of proper rate, depth, full release and with high compression fraction. To achieve this 15 reliably, training must address the ergonomics of proper CPR regarding the provider’s position relative 16 to the patient, hand position, locked extended arms as well as monitoring for signs of fatigue. Real-time 17 cues to improve CPR have been proven effective and include metronomes, devices measuring rate, 18 depth and release such as accelerometers or devices that measure the absolute distance between a 19 sensor on either side of the torso to provide true compression distance as compared to the 20 accelerometer that measures the sum of the movement which often includes the compression of the 21 substrate such as a mattress or stretcher pad. 22

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Appendix 3: Ventilation 24

Ventilation strategies are not as well defined as compression strategies. All of those who advocate 25 different methods recognize that in non-asphyxial adult OHCA early ventilation is not a high initial 26 priority relative to CPR and early defibrillation. The potential danger of excess ventilation causing 27 decreased CPR cardiac output is a recognized concern. The most common approach is ventilation at 30:2 28 or continuous interposed ventilation which has been studied and found equivalent. Some advocate for 29 passive ventilation using facemask oxygen delivery without ventilation for the first two or three cycles of 30 CPR. Observational studies have supported this approach. Airway strategies include passive ventilation, 31 bag-valve-mask, the use of supraglottic airways or endotracheal intubation. When invasive approaches 32 are used it is mandatory that the procedure does not lead to interruptions in CPR. In other words, 33 practitioners of SGA placement or endotracheal tubes must have as a core competency the ability to 34 reliably placing the devices during active CPR. 35

Ventilation parameters: 36

Rate: either 30:2 or continuous interposed 37

Volume: providers tend to give too large of a tidal volume. Strategies include the “tea cup” (or 38 “princess”) approach with compression using only thumb, index and long fingers to limit the delivered 39 volume or using smaller bags. 40

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EtCO2: the use of EtCO2 can be an adjunct for gauging ventilation. While EtCO2 has many benefits and 1 is strongly encouraged there are no studies that definitively define its use to guide ventilations during 2 cardiopulmonary arrest. Confounding features include the use of sodium bicarbonate and altered V/Q 3 relationships during cardiac arrest. 4

5

Appendix 4: Minimally Interrupted Cardiac Resuscitation (MICR) 6

MICR protocol implementation has been associated with improved survival from OHCA. xxix Here is a 7 sample MICR protocol: 8

9

10

11

Appendix 5: Defibrillation 12

Ventricular fibrillation progresses from a recognizable high amplitude grouped complexes with a steep r 13 wave that is relatively shock-sensitive to a more disorganized lower amplitude rhythm that becomes 14 shock refractory and ultimately becomes asystole. Chest compressions can improve a deteriorated 15 ventricular fibrillation to one that is more amenable to defibrillation. The best approach is early 16 defibrillation after an initial round of CPR while placing an AED or manual monitor defibrillator. (NOTE: 17 The fraction of patients who are in VF is only between 20-25%. HP-CPR is equally vital for patients with 18 non-shockable rhythms.) 19

Pulse checks and defibrillation can lead to unnecessary pauses in CPR. CPR cycles will typically be two 20 minutes. A crucial training component is the timing of the cycle with particular attention to the last 20-21 30 seconds. During this time the team leader should vocalize that there is 20 seconds until the next 22 pulse check and at that time the defibrillator should be charged. A crew member should locate the 23 compression pulse in the groin and maintain contact with that point when compressions are paused. 24 Knowing where the pulse should be is a critical time-saving technique. The device should be fully 25 charged at the moment of the pause for pulse check/rhythm check. Shock/no shock should be decided 26 and completed within 5 seconds with immediate resumption of compressions. 27

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While HP-CPR is fundamentally a BLS skill, many cardiac arrests receive ALS care. Consideration must be 1 given in training to the transition to ALS care or the integration of ALS care from the outset. 2

When ALS is present at the outset, training must be directed to the priorities of care which are 3 compressions and the placement of a monitor defibrillator or AED. As resources allow, the ALS steps 4 include establishment of IV or IO access, establishment of an airway if desired and then the use of ALS 5 drugs. When ALS arrives after the initial first responder or BLS care, an organized integration of this level 6 of care in a manner that does not disrupt the ongoing resuscitation should be a specific training point. 7 The specifics of the use and merits of ALS medications is beyond the scope of this document. 8

9

Appendix 6: Termination of Resuscitation 10

It is important to recognize the potential for life and to recognize futility. The following factors should be 11 considered: 12

o Whether the arrest was witnessed 13 o Whether Asystole as only rhythm 14 o Time from collapse 15 o EtC02 (less than 10 mmHg despite HP-CPR) 16

The decision to abandon resuscitation should involve team members and also family members. The 17 team leader should review the challenges that have been faced, any finding suggesting a potential for 18 improved outcome, the duration of the event and the responses to the interventions. All members 19 should have equal input in voicing concerns about termination as well as reasons f or going forward. 20 Family should be brought in to the discussion as well This should occur before engaging medical control 21 consult if that is required. 22

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Appendix 7: Transition to Mechanical CPR 24

Manual HP CPR and integration with mechanical CPR devices. Mechanical CPR devices are frequently 25 used in the provision of CPR. The 2015 ECC guidelines state: “The use of mechanical piston devices may 26 be considered in specific settings where the delivery of high-quality manual compressions may be challenging 27 or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac 28 arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR]), 29 provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices (Class 30 IIb, LOE C-EO). Furthermore, “Manual chest compressions remain the standard of care for the treatment of 31 cardiac arrest, but mechanical piston devices may be a reasonable alternative for use by properly trained 32 personnel. (Class IIb, LOE B-R) This statement reflects the available science. There may be merit in their 33 use but training in the application and use of the device is recognized as a foundational element. 34

Mechanical CPR is provided by one of two technologies, either compression-band or piston-type 35 devices. The specific method for applying each is different but application of any device to the patient’s 36 torso induces a pause in compressions that would not be present if only HPCPR were being done. 37 Therefore, the time to apply the device must be the absolute minimum that can be achieved and there 38 must be a perceived benefit that outweighs the potential risk. These benefits may include any of the 39

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indications noted above for the use of mechanical CPR. The device risks could include such things as a 1 prolonged pause to apply the device or delaying defibrillation in a witnessed VF arrest. Even if the 2 application is done in a highly competent manner it is important that this not disrupt the early 3 “choreography” of the resuscitation effort. Priorities of the “pit crew” should be established and 4 completed as determined by how the team has trained and operational priorities associated with the 5 event. In summary, the use of mechanical CPR should be “high performance” as well. 6

Agencies and institutions choosing to use this technology should develop guidelines, training and 7 process improvement that includes: 8

o A specific protocol describing best practice for the application of the device being 9 used that should include scenarios tailored to the expected operational 10 environment of those using the device. Some points to include: 11

o The indication for mechanical CPR in preference to manual CPR 12 o Clinical assessment of whether the device is indicated for a given patient, 13

for e.g. size limitations 14 o When in the course of the resuscitation to transition from manual to 15

mechanical 16 o Who directs the transition 17 o Specific goals for application-related pause 18 o Device malfunction recognition mandating quick transition back to manual 19

CPR with device troubleshooting done off the patient. 20 o A means for precise measurement of the metrics of the manual to mechanical CPR 21

transition as well as ongoing evaluation of the CPR metrics of mechanical CPR to 22 recursively confirm that the goals are being met 23

o Team training demonstrating and practicing the protocol, confirming timing and 24 competency of all members. 25

o Recurrent training on a frequent basis 26 o Interfacing with receiving facilities to orient their staff to the device and its use by 27

the agency during the implementation phase with follow up as necessary to account 28 for attrition and staff changes 29

o Support for a receiving facility if the resuscitation continues in the emergency 30 department of to another department such as radiology or the cath lab. Additional 31 supplies, e.g. batteries, may be needed as may technical knowledge. 32 33

For more on applying a mechanical CPR device, please see: 34 https://anchoragefire.viebit.com/player.php?hash=05hME6lLkd0S 35

36

Appendix 8: HP-CPR Resources 37

Additional HP-CPR training and CQI esources can be found at: 38

http://www.resuscitationacademy.org/downloads/HPCPRToolkit110309.pdf 39

https://mycares.net/ 40

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PART 3: ABOUT THE INITIATIVE—PARTICIPANTS IN THE EXPERT PANELS AND THE PROCESS FOR CREATING THE TOOLKIT

(Editor’s Note: To be included in final document) Working Committee Rosters: