The annual incidence of people who experience an out-of-hospital cardiac arrest (OHCA) requiring resuscitation is 57.8 per 100000 population (1). Telephone-assisted cardiopulmonary resuscitation (T-CPR) is a highly effective measure that increases survival in these patients (2). For T-CPR, the rescue center dispatcher instructs the caller during the emergency call on how to carry out CPR until emergency medical service (EMS) personnel arrive. T-CPR has been recommended in the resuscitation guidelines since 2010 (3). The present study is the largest data collection on the implementation status of T-CPR in Germany to date.
Acknowledgments
Translated from the original German by Veronica A. Raker, PhD.
Footnotes
Funding
The study was funded by the ADAC Foundation.
Conflict of interest statement:
Dr. Wingen is executive personal assistant of the Board of the German Resuscitation Council (GRC).
Prof. Böttiger has received fees for lectures in the framework of continuing education from MVW Medizinisch Wissenschaftliche Verlagsgesellschaft, Deutschlandfunk, Novartis Pharma, C. R. Bard, Bard Limited, Forum für medizinische Fortbildung FomF, Lücke Kongress, Philips Market DACH, Deutscher Ärzteverlag, Bioscience Valuation BSV, Westdeutscher Rundfunk, mekontor, Akademie für Arztliche Fortbildung – Ärzteakademie c/o Asklepios Klinik St. Georg, Springer Medien Verlag, C.T.l zoll Medical Deutschland, and Mhoch2 TV-Produktionsgesellschaft.
Prof. Kreimeier is member of the Executive Committee of the GRC.
The remaining authors declare that no conflict of interest exists.
Methods
A prospective field study was carried out from 24 June to 19 July, 2021 and was supported by the German Association of Rescue Coordination Centers (Fachverband Leitstellen e.V.). Leads or deputy leads of dispatch-centers were asked about the implementation status and the content of T-CPR in their center, using a web-based, validated questionnaire. After giving comprehensive information to the study participants, data were collected strictly anonymously. The study was approved by the ethics committee of the University of Cologne (ID no. 21–1176) and was registered in the German Clinical Trials Register (DRKS00025726). The study data were statistically analyzed using IBM SPSS. Absolute and relative characteristics (n/%) are shown.
Results
All 249 dispatch centers in Germany were included in the study. The response rate to the questionnaire was 67% (n = 166). All participants stated that they perform T-CPR (166/100%) (table 1). However, fewer than half of the participating dispatch centers (73/44%) achieved a sufficient implementation rate (e.g., percentage of T-CPR for clearly recognized OHCA) (>80%). Training as well as internal and external specifications were described as the most common success factors for the implementation and performance of T-CPR. Table 2 shows an overview of all success factors and barriers for implementation of T-CPR.
Table 1. Implementation of T-CPR and characteristics of the participating dispatch centers.
| Providing T-CPR (n = 166)*1 | n (%) |
| Yes | 166 (100) |
| No | 0 (0) |
| Number of total emergency calls (n = 150)*2 | n (%) |
| <50 000 | 41 (27.3) |
| 50 001–100 000 | 74 (49.3) |
| >100 000 | 35 (23.3) |
| Number of emergency calls related to suspected OHCA (n = 134)*2 | n (%) |
| <100 | 24 (17.9) |
| 100–300 | 58 (43.3) |
| 301–500 | 15 (11.2) |
| >500 | 10 (7.5) |
| Information not collected | 27 (20.1) |
| Percentage of T-CPR in clearly identified OHCA (implementation rate) (n = 166) | n (%) |
| 1% to 20% | 16 (9.6) |
| 21% to 40% | 15 (9.0) |
| 41% to 60% | 17 (10.2) |
| 61% to 80% | 45 (27.1) |
| 81% to 100% | 73 (44.0) |
*1 Response rate: 67% of the total 249 dispatch centers included
*2 Data refer to the year 2020
OHCA, out-of-hospital cardiac arrest; T-CPR, telephone-assisted cardiopulmonary resuscitation
Table 2. Factors that lead to the success or hindrance of T-CPR implementation in dispatch centers.
| Success factors for T-CPR implementation* | n (%) |
| Training courses | 122 (73.5) |
| Internal guidelines | 110 (66.3) |
| External guidelines | 91 (54.8) |
| Sufficient technical equipment | 83 (50.0) |
| Feedback after successful T-CPR | 71 (42.8) |
| Having more personnel | 9 (5.4) |
| Barriers for T-CPR implementation* | n (%) |
| High volume of emergency calls at the same time | 78 (47.0) |
| Personnel shortages | 45 (27.1) |
| Insufficient qualification of dispatchers | 35 (21.0) |
| OHCA indicators difficult to detect in a call | 35 (21.0) |
| Lack of technical equipment | 31 (18.7) |
| No internal guidelines | 24 (14.5) |
| No external guidelines | 15 (9.0) |
*Data refer to all n = 166 participants; multiple answers possible. OHCA, out-of-hospital cardiac arrest; T-CPR, telephone-assisted cardiopulmonary resuscitation
T-CPR provided by the dispatch centers was based on higher-level recommendations/guidelines (120/72%), internal working instructions (113/68%), the dispatchers’ own initiative (82/49%), and legal regulation (23/14%). Overall, 78% of the participants supported a legal obligation for T-CPR. During the emergency call, only 49% of the dispatch centers systematically asked about the presence of gasping (indicative of cardiac arrest). In 21% of the dispatch centers, the target group for T-CPR was not defined, and decisions were made by the dispatchers based on individual case decision. A further 5% of the participants only carried out T-CPR for children, 4% only for adults, and 69% for both children and adults. T-CPR instructions for ventilation were also handled inconsistently: in 43% of the dispatch centers, they were given by dispatchers based on individual case decisions; in 9%, they were always given; in 21%, they were given only for selected patient groups/situations; and in 28%, they were not given at all. Dispatcher training for T-CPR took place in 80% of the dispatch centers.
Discussion
With 166 participants, the present study is one of the largest study on the implementation status of T-CPR in dispatch centers in Germany. T-CPR was implemented in all dispatch centers that participated in the study. In 2014, the rate was only at 76.8% (4). However, the frequency of T-CPR still remains insufficient. A dispatcher carries out this highly effective and life-saving measure only in one out of four cases of OHCA treated by EMS (1). Bystander CPR is performed in 70% of these cases (2). The content-related design of T-CPR, in terms of the general framework, the target groups, and the use of structured processes to detect OHCA, show a high level of diversity in the available data—with a high percentage of individual case decisions being made.
The study results also show that the purely “recommended” character of T-CPR, as given in the resuscitation guidelines since 2010, is not sufficient to ensure that all persons in Germany who have OHCA will receive lifesaving T-CPR. An approach to be discussed is therefore the legal regulation of T-CPR, as has been established in the federal state of Schleswig-Holstein. Higher-level guidelines, like a T-CPR algorithm for all dispatch centers, such as seen in Bavaria, help to standardize T-CPR. In addition, these also promote more consistent implementation of T-CPR. Our data show that the dispatch centers in both federal states also have correspondingly high implementation rates. In addition, T-CPR training for dispatchers is an important success factor, as OHCA is often not recognized during the emergency call, and consequently no T-CPR is provided. In contrast to current guideline recommendations, 20% of the dispatch centers in the present study do not provide corresponding T-CPR trainings. (3). Data from Luiz et al. also show that the use of structured emergency calls doubles the implementation rate of T-CPR (5). In the present study, such a system is used in only about half of the dispatch centers (82/52%). Thus, there is an urgent need for further action in this area (5).
In summary, our results show that T-CPR is still not sufficiently implemented in a quantitative manner in more than half of the dispatch centers in Germany that participated in this study. Implementation rates should be further increased in a definitive and sustainable manner, in order to improve survival after OHCA. More legal requirements, training courses, and standards are important starting points for standardizing and expanding T-CPR nationwide.
Interpretation of the results of this study must take into account that all of the information is self-assessment by the leads of the surveyed dispatch centers. Objective data verification was not performed. The 100% implementation rate of T-CPR refers only to the 166 participating dispatch centers. It might bepossible that other dispatch centers in Germany that did not take part in the study (n = 83/33%) do not carry out T-CPR.
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