The first links in the Chain of Survival for out-of-hospital cardiac arrest (OHCA) are well established as being critical steps for survival. The role of the call-taker (also known as dispatcher) is pivotal in these links through ensuring the earliest possible recognition of a cardiac arrest and the earliest possible resuscitation interventions by a bystander. In this regard, call-takers are on the front line of emergency medical services (EMS) even if their roles are not as visible as those of paramedics. There is now a significant body of evidence that has identified the facilitators and barriers in emergency calls for cardiac arrest recognition and the delivery of cardiopulmonary resuscitation (CPR) and defibrillation.1., 2., 3. It is pleasing to see the many studies, exploring methods to evaluate and improve the dispatch system, that have featured in Resuscitation Plus since it launched in 2020.
In this issue of the journal, Byrsell et al.4 examine a criteria-based medical index dispatch system and compare their findings to the benchmarking goals recently published in the Telecommunicator CPR (t-CPR) Policy Statement by the American Heart Association (AHA).5 Their emergency call audit found that some performance goals were exceeded (e.g. the proportion of recognised OHCA), but others fell short, specifically in the time taken to OHCA recognition and dispatch-directed compressions. Given these significant delays, the authors recommend that a simpler version of questioning may save time, such as the two-question composition of the NO-NO-GO algorithm. In this algorithm, if the answer to critical screening questions, “is the patient conscious (awake)?” and “is the patient breathing normally?”, is no, then t-CPR should be inititated immediately.6
Of novel interest, Byrsell et al. estimate the number of potential additional OHCA survivors if each of the AHA performance goals is met. Extrapolated for the whole of Sweden, this translates into a potential saving of 192 additional lives through improved time to OHCA recognition and 462 lives through improved time to dispatch-directed compressions. The calculation of potential additional survivors is likely to be a useful method for EMS to identify how and where to improve their dispatch system for the greatest gain.
Also of interest is another study, published in Resuscitation Plus by Gram et al.,7 which examined the implementation of a quality improvement intervention in a dispatch system using the NO-NO-GO algorithm. By conducting regular call-taker education sessions and providing feedback from audited calls, these authors reported a significant improvement in OHCA recognition, but not in the key time intervals of the call-taking process. However, the times reported by Gram et al. at baseline were close or already below the AHA minimum standards, and were much shorter than the Byrsell et al. study.
The value of turning audio recordings of emergency OHCA calls into transcripts was promoted in 2014, by Gareth Clegg and his team, for the purpose of qualitative and quantitative analysis to pinpoint, more specifically, what the hold-ups are in caller-call-taker interactions.8 The application of such an approach is highlighted in another Resuscitation Plus paper, in which van Rensburg et al.9 identified common themes within caller descriptors of the patient (in multiple languages) in order to improve the identification of OHCA cases in their unscripted call-taking system in South Africa.
There is also emerging evidence of the value of a systematic and sophisticated linguistic analysis of emergency calls in order to isolate communication breakdowns and patterns, as well as identify the impact of specific words and phrasing on subsequent actions and timings. Through the application of linguistics, the answers to many communication problems are revealed via close examination of the transcripts. Less-than-optimal communication outcomes can be associated with a variety of factors including the use of particular standardised call scripts which place restrictions on the kinds of “talk” the parties can engage in.
Our own group’s research has focussed on a commonly used standardised protocol named the Medical Priority Dispatch System (MPDS) and has identified key barriers to bystanders providing CPR and significant linguistic aspects of OHCA call communication.10., 11., 12. We encourage the field to look at what qualitative linguistic analysis can offer in the understanding of why there are time delays and how call-takers and callers themselves can provide the solutions to shortening these critical times.13., 14., 15. Linguistics, as a discipline, has a body of knowledge on the dynamics of service encounters, institutional communication, and the particularity of emergency service interactions, with interdisciplinary research collaborations between linguists and EMS looking set to expand in the near future. Linguistic analysis will enhance our understanding of how to target issues in OHCA calls such as the handling of emotional callers, cases of miscomprehension, and language barriers. Given the high importance of early recognition and basic life support, enhancing communication and optimising the emergency call has great potential to improve patient outcomes.
Funding
JB is funded by a Heart Foundation Fellowship (#104751). JF is funded by a National Health and Medical Research Council Investigator Grant (##1174838), which also provides salary support for NP.
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Janet Bray is an Associate Editor of Resuscitation Plus.
References
- 1.Kirby K., Voss S., Bird E., Benger J. Features of Emergency Medical System calls that facilitate or inhibit Emergency Medical Dispatcher recognition that a patient is in, or at imminent risk of, cardiac arrest: A systematic mixed studies review. Resusc Plus. 2021;8 doi: 10.1016/j.resplu.2021.100173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Fukushima H., Bolstad F. Telephone CPR: Current status, challenges, and future perspectives. Open Access Emerg Med OAEM. 2020;12:193–200. doi: 10.2147/OAEM.S259700. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Case R., Cartledge S., Siedenburg J., et al. Identifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: A qualitative review of emergency calls. Resuscitation. 2018;129:43–47. doi: 10.1016/j.resuscitation.2018.06.001. [DOI] [PubMed] [Google Scholar]
- 4.Byrsell F., Claesson A., Jonsson M., Ringh M., Svensson L., Nordberg P., Forsberg S., Hollenberg J., Nord A. Swedish dispatchers’ compliance with the American Heart Association performance goals for dispatch-assisted cardiopulmonary resuscitation and its association with survival in out-of-hospital cardiac arrest: A retrospective study. Resusc Plus. 2021 doi: 10.1016/j.resplu.2021.100190. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Panchal A.R., Berg K.M., Cabañas J.G., et al. 2019 American Heart Association focused update on systems of care: Dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers: An update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019;140:e895–e903. doi: 10.1161/CIR.0000000000000733. [DOI] [PubMed] [Google Scholar]
- 6.Berg K.M., Cheng A., Panchal A.R., et al. Part 7: Systems of care: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142:S580–604. doi: 10.1161/CIR.0000000000000899. [DOI] [PubMed] [Google Scholar]
- 7.Gram K.H., Præst M., Laulund O., Mikkelsen S. Assessment of a quality improvement programme to improve telephone dispatchers’ accuracy in identifying out-of-hospital cardiac arrest. Resusc Plus. 2021;6 doi: 10.1016/j.resplu.2021.100096. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Clegg G.R., Lyon R.M., James S., Branigan H.P., Bard E.G., Egan G.J. Dispatch-assisted CPR: Where are the hold-ups during calls to emergency dispatchers? A preliminary analysis of caller–dispatcher interactions during out-of-hospital cardiac arrest using a novel call transcription technique. Resuscitation. 2014;85:49–52. doi: 10.1016/j.resuscitation.2013.08.018. [DOI] [PubMed] [Google Scholar]
- 9.van Rensburg L.C., Richmond L., Mgidi S., Claassen J., Wylie C., Stassen W. The lay descriptors of out-of-hospital cardiac arrest in the Western Cape province, South Africa. Resusc Plus. 2021;7 doi: 10.1016/j.resplu.2021.100146. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Perera N., Ball S., Birnie T., et al. “Sorry, what did you say?” Communicating defibrillator retrieval and use in OHCA emergency calls. Resuscitation. 2020;156:182–189. doi: 10.1016/j.resuscitation.2020.09.006. [DOI] [PubMed] [Google Scholar]
- 11.Riou M., Ball S., Whiteside A., et al. Caller resistance to perform cardio-pulmonary resuscitation in emergency calls for cardiac arrest. Soc Sci Med. 2020;256 doi: 10.1016/j.socscimed.2020.113045. [DOI] [PubMed] [Google Scholar]
- 12.Riou M., Ball S., Williams T.A., et al. ‘She’s sort of breathing’: What linguistic factors determine call-taker recognition of agonal breathing in emergency calls for cardiac arrest? Resuscitation. 2018;122:92–98. doi: 10.1016/j.resuscitation.2017.11.058. [DOI] [PubMed] [Google Scholar]
- 13.Perera N, Riou M, Ball S, Birnie T, Morgan A, Whiteside A, et al. The trajectory of repairs in the defibrillator sequence during emergency cardiac arrest calls – balancing progressivity and intersubjectivity. Commun Med in press.
- 14.Riou M., Ball S., O’Halloran K.L., Whiteside A., Williams T.A., Finn J. Hijacking the dispatch protocol: When callers pre-empt their reason-for-the-call in emergency calls about cardiac arrest. Discourse Stud. 2018;20:666–687. [Google Scholar]
- 15.Riou M., Ball S., Williams T.A., et al. ‘Tell me exactly what’s happened’: When linguistic choices affect the efficiency of emergency calls for cardiac arrest. Resuscitation. 2017;117:58–65. doi: 10.1016/j.resuscitation.2017.06.002. [DOI] [PubMed] [Google Scholar]