No fear: Willingness of smartphone activated first responders to assist with cardiac arrest during the COVID-19 pandemic

Abstract

Aim

To understand the fear and willingness to respond of smartphone activated first responders during the COVID-19 pandemic.

Methods

We invited smartphone activated first responders registered with the GoodSAM application in Victoria, Australia to take part in an online survey in November 2020. We assessed willingness to respond to an alert and provide CPR during the pandemic and administered the Fear of COVID-19 Scale questionnaire. Regression analysis was conducted to investigate associations between occupation, clinical training, and years of clinical experience with willingness to respond and fear of COVID-19.

Results

The survey response rate was 5.1%. Responders (n = 348) had a median age (interquartile range) of 46 years (33–55). Most (67%) were aged 30–59 years and 43% were female. Responders spanned several occupations including paramedics (12.6%), registered nurses (14.7%), and non-clinical individuals (21.8%). Most (92%) reported they would feel comfortable responding to a GoodSAM alert during the pandemic. Almost all (>95%) reported they would provide CPR. About 20% reported being afraid of COVID-19 but only 3.2% reported they had a high-level of fear of COVID-19. The odds of paramedics being willing to respond to an alert was reduced by 73% during the pandemic (OR 0.27, 95% CI 0.11 to 0.69). No other associations were found with willingness or fear of COVID-19.

Conclusion

Although willingness was high and fear of COVID-19 was low, some smartphone activated first responders were less willing to respond to an alert during the pandemic. These findings may inform future pandemic planning and decision-making around pausing first-responder programs.

Introduction

Providing early intervention in out-of-hospital cardiac arrest (OHCA) is critical to maximising survival and favourable neurological outcomes. Bystanders are an essential link in the chain of survival and can improve patient outcomes by providing cardiopulmonary resuscitation (CPR) and defibrillation using an automated external defibrillator (AED) prior to paramedic arrival.¹ In multiple jurisdictions worldwide, crowdsourcing smartphone applications are also used as an important element of the OHCA system-of-care, alerting registered members of the public to nearby OHCA². Responders contribute to resuscitation efforts by arriving before emergency services and accelerating the initiation of CPR and AED use.

The COVID-19 pandemic has disrupted early links in the chain of survival, leading to poorer patient outcomes worldwide.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 During a critical time in the COVID-19 pandemic in Victoria, Australia, prior to vaccination development and when case numbers were high (>6,000) and strict social restrictions were in place, the smartphone application employed (“GoodSAM”) was deactivated due to the perceived potential risk of COVID-19 transmission to responders or other bystanders present. The deactivation period continued for 208 days. Other regions also changed their management of first responder programmes in response to the pandemic.¹⁵ Multiple regions also reported decreased rates of bystander CPR and AED application during the pandemic.4, 5, 8, 10, 11, 12, 16, 17 It is unknown, however, whether smartphone activated first responders would have been willing to act on alerts during the time of deactivation or whether the fear of COVID-19 was too great. Similarly, it is unknown if the decrease in bystander CPR and AED usage rates seen internationally were due to decreased willingness and increased fear of COVID-19.

We sought to examine the willingness of GoodSAM smartphone activated first responders to respond to alerts for suspected OHCA during the COVID-19 pandemic in Victoria, Australia, in addition to responder attitudes and fears of COVID-19.

Methods

Study design and setting

A cross-sectional, self-administered online survey with closed-ended questions was conducted in Victoria, Australia which has a population of 6.5 million. Ambulance Victoria is the sole provider of Emergency Medical Services (EMS) in Victoria. Suspected OHCA identified during an emergency call receives a three-tiered response including dispatch of community emergency response teams (where available) and fire services (where available), advanced life support paramedics and mobile intensive care paramedics. In addition, up to 3 registered GoodSAM responders are alerted via the smartphone app to nearby arrests occurring within a 500 m radius in metropolitan areas and a 5 km radius in regional areas at the time of the emergency call.

Study population

All registered GoodSAM responders in Victoria (n = 6,854) were invited to take part in this survey. An email invitation was sent out with a link to the study Explanatory Statement and questionnaires on 12 November 2020, immediately following the “second wave” of COVID-19 in Victoria, a 112-day lockdown from 9 July 2020, and a GoodSAM deactivation period (23 March 2020 to 16 October 2020). The survey link remained active for 10 weeks. All GoodSAM responders were alerted via email and text message that the system had been reactivated in October 2020 following the end of lockdown and when it was considered safe to do so.

Study tools

The structured survey was anonymous and delivered in English via the online Qualtrics platform. The questionnaire took participants a mean of 5.4 minutes to complete. We asked seven binary or multiple-choice socio-demographic questions (age, gender, current occupation, number of years of clinical experience [if applicable], living with or without family members) and questions related specifically to willingness to respond to OHCA during the COVID-19 pandemic and the provision of CPR (one binary and four multiple choice questions).

Fear of COVID-19 was assessed using the Fear of COVID-19 scale (FCV-19S)¹⁸ which has seven items, the responses of each were measured using a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree). Scores were categorised into low (scores 7–21) and high (scores 22–35) fear of COVID-19 as defined by Rahman et al (2020) who administered the FCV-19S in a general Australian population which included frontline workers.¹⁹

Data analyses

Data was downloaded from Qualtrics and analysed using STATA version 16. Descriptive statistics are presented as frequencies and proportions for categorical data and median and interquartile range (IQR) for continuous variables. Age and gender-adjusted logistic regression analysis was conducted to identify associations between willingness to respond and low fear of COVID-19 with occupation, clinical training versus none, and number of years of clinical experience. Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were calculated. Age and gender-adjusted linear regression analysis was conducted to investigate correlations between total FCV-19S score, occupation, clinical experience versus none, and number of years of clinical experience. A p-value of <0.05 (two-sided) was considered statistically significant.

Ethics

Ethics approval was obtained from Monash University Human Research Ethics Committee (#24377). Information on support services to contact was included at the end of the survey for any participant feeling distressed while completing the study questionnaire.

Results

A total of 348 GoodSAM community first responders (a 5.1% response rate) participated in this study, all from Victoria, Australia. One respondent did not answer all questions about responding to a GoodSAM alert and three respondents did not complete the FCV-19S. Most survey responses were received in November 2020 with six responses received in December and one response received in January 2021.

Participant characteristics

Table 1 demonstrates the characteristics of participating GoodSAM responders. With an overall median (IQR) age of 46 (33, 55) years, most participants (67%) were aged 30–59 years. Almost 43% of participants were female. Participants were from a wide range of occupations; almost one third identified as frontline workers (paramedics, nurses, or medical physicians), 36% were in other first responder occupations (State Emergency Service workers, first aiders, basic life support trained individuals employed by a private provider, lifesavers, EMS volunteers, fire fighters), and 22% were not in a medical or first responder occupation. Those with a clinical background had a median (IQR) of 12 (5, 23) years of experience. Seventy percent of participants were either married or living with a partner and resided with their family during the COVID-19 pandemic period.

Table 1.

Characteristics of GoodSAM smartphone activated first responder survey participants.

Characteristics	n = 348
Age in years, median (IQR)	46 (33, 55)
<30 years, n (%)	67 (19.2%)
30–59 years, n (%)	233 (67.0%)
60+ years, n (%)	48 (13.8%)
Female gender, n (%)	148 (42.5%)
Current occupation, n (%)
Paramedic	44 (12.6%)
Registered Nurse	51 (14.7%)
Medical physician	9 (2.6%)
Student (medical/paramedicine/nursing)	18 (5.2%)
State Emergency Services	9 (2.6%)
First aider/BLS paramedic/lifesaver	41 (11.8%)
EMS volunteer	34 (9.8%)
Fire fighter (Inc. volunteers)	41 (11.8%)
Non-medical occupation	76 (21.8%)
Retired	14 (4.0%)
Unspecified	11 (3.2%)
Years of clinical experience, median (IQR)	12 (5, 23)
Married or living with partner	243 (69.8%)
With children	217 (62.4%)
Resided with family during COVID-19 pandemic	244 (70.1%)

IQR interquartile range; BLS Basic Life Support; EMS Emergency Medical Services.

Responding to a GoodSAM alert during COVID-19

Most study participants (92%) reported they would feel comfortable responding to a GoodSAM alert for suspected OHCA during the COVID-19 pandemic (Table 2). The fear of both contracting and spreading the virus meant that the remaining 8% would not feel comfortable responding to a GoodSAM alert. Almost all (>95%) indicated they would provide CPR to anyone who required treatment. Forty percent of participants reported they would provide CPR with ventilations. Upon being hypothetically offered provision of personal protective equipment, 95% of participants said they would feel more comfortable to respond to a GoodSAM alert. In the age and gender-adjusted logistic regression analysis, we found that the odds of paramedics being willing to respond to a GoodSAM alert was reduced by 73% during COVID-19 (OR 0.27, 95% CI 0.11 to 0.69, p = 0.006; data not shown) (Supplementary Table 1). No further associations were found between willingness to respond to an alert and any other occupation, clinical training versus none, or number of years of clinical experience (Supplementary Table 2).

Table 2.

Willingness of GoodSAM smartphone activated first responder survey participants to respond to OHCA during the COVID-19 pandemic period.

Characteristics	n=348
Would you feel comfortable responding to a GoodSAM alert during the COVID-19 pandemic?
Yes	320 (92.0%)
No	28 (8.0%)
Due to fear of contracting the virus	9 (32.1%)
Due to fear of spreading the virus	0 (0.0%)
Due to contracting and spreading the virus	16 (57.2%)
Other reason	3 (10.7%)
Would you provide CPR during the COVID-19 pandemic?*
Yes – to anyone who requires treatment	331 (95.4%)
Yes – but only if I knew the person or they were a child	10 (2.9%)
Yes – but only if I knew the person	3 (0.9%)
Yes – but only if they were a child	0 (0.0%)
No – I would not provide CPR to anyone during the COVID-19 pandemic	3 (0.9%)
What type of CPR would you feel comfortable providing?*
Compression-only CPR	208 (59.9%)
Ventilation-only CPR	1 (0.3%)
Compressions and ventilations	138 (39.8%)
If you were provided with personal protective equipment (PPE), would you feel more comfortable to respond to a GoodSAM alert?*
Yes	285 (82.1%)
Maybe	44 (12.7%)
No	18 (5.2%)

*One participant did not complete this question.

FCV-19S

Of the 345 individuals who completed this questionnaire, 19.7% agreed with the statement “I feel most afraid of COVID-19”, with 47.5% reporting they disagreed or strongly disagreed with this statement (Fig. 1). Less than 2% of participants reported experiencing a physiological response when thinking about COVID-19; 0.6% reported having clammy hands, 1.8% reported insomnia due to worrying about getting COVID-19, and 1.5% reported experiencing a racing heart or palpitations. When asked if they felt uncomfortable when thinking about COVID-19, 11.3% reported they agreed or strongly agreed with the statement. Just over 5% reported they felt they were afraid of losing their life because of COVID-19, and 7.5% agreed that when watching the news and stories about COVID-19 on social media that they became nervous or anxious. The median (IQR) overall FCV-19S score was 12 (9, 14) (Fig. 2). Eleven of the 345 respondents (3.2%) met the criteria for a high fear of COVID-19 (scores 7–21) compared to 96.8% who met the criteria indicating a low fear of the virus (scores 22–35).

Fig. 1.

Responses from GoodSAM smartphone activated first responders to individual items of the FCV-19S.

Fig. 2.

FCV-19S total score for GoodSAM smartphone activated first responders.

In age and gender-adjusted linear regression analysis, no significant associations were found between the FCV-19S score and occupation, clinical training versus none, or number of years of clinical experience (Supplementary Table 3).

Discussion

This study examined the willingness of GoodSAM smartphone activated first responders to continue acting in their role as essential contributors in the OHCA chain of survival during the COVID-19 pandemic. Our cohort included off-duty frontline workers and non-medical workers which is encouraging. We demonstrated that GoodSAM responders are still willing to assist during OHCA despite the pandemic and the potential for infection. Ninety-two percent of responders reported that they would still respond to a GoodSAM alert and more than 95% stated that they would still provide CPR (40% with ventilations). Our work complements data from other regions where the willingness of bystanders to provide CPR did not waver during the COVID-19 pandemic.3, 20, 21, 22

Although almost 20% of responders reported being afraid of COVID-19, almost 97% reported that their fear of COVID-19 was low. The reported 73% reduced odds of paramedics (12.6% of the cohort) responding to a GoodSAM alert is likely due to various reasons such as psychological distress caused by seeing first-hand the impact of COVID-19 on patients and colleagues prompting every effort to avoid infection for themselves and their families, already feeling overly exposed to COVID-19 through their work or feeling the need to switch off outside the workplace given the significant increase in workload seen during the pandemic period. A systematic review conducted by Muller et al (2020) involving 59 studies and 54,707 participants demonstrated that 20–25% of healthcare professionals reported a significant increase in mental health issues, psychological distress and sleep disorders during the pandemic which was associated with increased workload.²³

In the study conducted in June 2020 by Rahman and colleagues, 587 individuals in the general Australian population were recruited to take part in an online survey to understand psychological distress, fear, and coping strategies during the COVID-19 pandemic.¹⁹ Participants had an average age of 41 years and were recruited through general practice, allied health practice and community groups across Australia. Unlike our findings, those who identified themselves as frontline workers (42.3%) were more likely to have lower levels of fear of COVID-19 than other study participants. However, it was unclear what proportion of those who identified as frontline workers were paramedics. In addition, >88% of the cohort resided in the state of Victoria and the dates of administration were prior to the 112-day lockdown imposed in Victoria, one of the longest worldwide. Furthermore, females have consistently demonstrated higher levels of fear and distress than their male counterparts, and almost 62% of the cohort in the study by Rahman et al were female unlike our study in which 43% were female.24, 25, 26

Our study has some limitations that require comment. Firstly, although the aim of our survey was to understand the attitudes of GoodSAM first responders with hypothetical questions, it is possible that responders may have been alerted to and attended a nearby OHCA prior to undertaking the survey. Secondly, questions relating to responding to a GoodSAM alert were not pre-tested or validated due to the rapidity we required to administer the survey at this significant point in time. Third, given the low survey response rate, validity cannot be ensured, and non-response bias may have been introduced. In addition, no reminder was sent to registered GoodSAM first responders to complete the survey which may have limited our final sample size. There is also the possibility that responses may have differed given a different pandemic trajectory.

Conclusion

This study confirmed that most smartphone activated first responders, with the exception of paramedics, remain willing to assist in the response to OHCA despite the COVID-19 pandemic. Timely assistance for OHCA and appropriate intervention provided by responders remains available in this context. Our data may inform future pandemic planning and decision making, with smartphone activated first responders likely to remain willing to assist in resuscitation attempts within a pandemic context.

Sources of funding

ZN is supported by a National Heart Foundation of Australia Future Leader Fellowship (105690). DS is supported by a National Heart Foundation of Australia Future Leader Fellowship (101908).

CRediT authorship contribution statement

Jocasta Ball: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Visualization, Project administration. Emily Mahony: Methodology, Data curation, Writing – review & editing, Project administration. Michael Ray: Writing – review & editing, Project administration. Ziad Nehme: Methodology, Writing – original draft, Writing – review & editing. Dion Stub: Writing – review & editing. Karen Smith: Conceptualization, Resources, Writing – review & editing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

The following are the Supplementary data to this article:

Supplementary data 1

Supplementary Tables of regression models demonstrating the association between willingness to respond and fear of COVID-19 with occupational characteristics.