Barriers to dispatcher-assisted cardiopulmonary resuscitation in Thailand

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) stands as a prominent cause of mortality worldwide reflecting global patterns.¹ Throughout the Asia-Pacific region, OHCA survival rates remain generally low, ranging from 2 to 11%.² Moreover, this ranging was drop down to 0.5-8.5% in 2015.³ Specifically, in Thailand, the survival rate for hospital discharge was measured at discharged alive after 30 days, comprising 22 (8.6%), 8 (3.0%), and 12 (1.7%) from regional, suburban-capital, and urban-capital centers, respectively.⁴ Effective management of OHCA crucially relies on the "chain of survival" paradigm, emphasizing prompt initiation and seamless execution of rescuer interventions. An essential element of this chain is the early initiation of CPR, known to enhance OHCA outcomes significantly.⁵ Given that OHCA incidents typically occur outside the immediate reach of healthcare professionals, timely CPR initiation heavily depends on bystanders' recognition of cardiac arrest and their administration of CPR, which can more than double the patient's likelihood of survival, especially in long-term outcome.^6,7

Recently, dispatcher-assisted CPR (DA-CPR) has emerged as a potent intervention aimed at bolstering bystander CPR rates and consequently improving OHCA outcomes.⁸ This approach operates on the premise that when a bystander contacts emergency medical services (EMS), the call not only triggers dispatch assistance but also presents an opportunity for EMS personnel to prompt recognition of cardiac arrest and prompt initiation of bystander CPR through systematic questioning and real-time pre-arrival instructions. Indeed, DA-CPR has demonstrated the potential to nearly double the percentage of OHCA patients who receive bystander CPR.⁹

The research conducted across different regions of Asia has revealed that the percentage of OHCA victims receiving bystander CPR ranges from 10.5 to 79.0 percenatges.¹⁰ However, the survival-to-discharge rate is as low as 4 percenatges.³ Nowadays, Thailand's population has a greater number of bystander CPR training in the community.^11-16 Given this context, there was a belief that DA-CPR by emergency medical dispatchers (EMDs) could be valuable in improving bystander CPR rates. However, offering regular CPR education or training to lay rescuers could enhance the quality of bystander CPR by utilizing an efficient DA-CPR protocol, consequently resulting in better outcomes for individuals experiencing sudden cardiac arrest. It suggests that individuals who undergo frequent CPR education or training become adept at this life-saving.¹⁶ Similarly, within the DA-CPR protocol, the median time from notification to the initiation of chest compressions performed by a bystander was thirty-nine seconds. In contrast, the median interval between notification and the start of chest compressions instructed over the phone was two hundred ninety-eight sec.¹⁷ Therefore, numerous factors can deter a bystander from performing CPR. These include concerns about contracting an infection, the lack of personal protective equipment (PPE), and discomfort with administering CPR to a stranger or someone unfamiliar in Indonesia.¹⁸ We hypothesized that DA-CPR would facilitate a higher incidence of CPR administration by addressing some of the barriers encountered by the emergency callers. Insights gained from this investigation could guide the implementation of DA-CPR in other developing emergency medical services (EMSs) systems in the Thailand. This study sought to identify the barriers hindering callers from initiating chest compressions.

METHODS

We undertook a retrospective cohort study of OHCA incidents within a major metropolitan EMS system in 3 regions; Mahasarakham (Northeast), Songkhla (South), and Prachinburi (Central), from January to December 2021. OHCA cases occurring after EMS arrival and those not in cardiac arrest at the time of the 1669 call were excluded a priori. Approval for the study was obtained from the human research ethics committee, at Mahasarakham university no. 208-238/2565

Data for OHCA patients treated by bystanders in 2021 were gathered retrospectively. Audio recordings linked to these incidents underwent review by EMDs using a comprehensive checklist covering all pertinent variables. Inclusion criteria comprised OHCA patients who sought assistance via a bystander's call to the dispatch center and were subsequently transported to the hospital by emergency medical providers. Exclusions were made for cardiac arrest cases occurring in nursing homes, doctors' offices, jails, or unknown locations, with a focus on non-healthcare professionals. Additionally, cases were excluded if a language barrier impeded the dispatch process, if emergency medical providers witnessed the OHCA, or if the caller was not present with the patient. Calls were further excluded from CPR process analysis if bystanders performed CPR before receiving CPR instructions, or if the audio was incomplete or fragmented. The DA-CPR protocol mandates compression-only CPR for adult arrests, with EMDs expected to provide CPR instructions upon reports of unconsciousness, apnea, or agonal breathing.

Measurement and analysis

The authors defined DA-CPR as CPR instructions initiated by EMDs, prompting bystanders to start chest compressions. The reason why the bystander did not perform CPR is described as the bystander's decision not to administer CPR even after receiving instructions from EMDs upon recognizing signs and symptoms. Data on the variables related to bystander refusal to perform CPR were gathered using the Pan-Asian resuscitation outcomes study (PAROS) dispatcher CPR form.¹⁹ Data collection involved the PAROS dispatcher CPR form and qualitative information from dispatchers. Descriptive statistics and content analysis were employed for data analysis.

RESULTS

From the characteristics of the OHCA as indicated in Table 1, the majority of calls were made by relatives (72.5%). Additionally, a significant proportion (91%) of callers had never undergone CPR training. Exploring general characteristics relevant to CPR, certain variables were identified, including the location of the incident (resident or public), and the relationship between the informant and the patient. While a small number of bystanders had received CPR training, the majority of those attempting CPR were relatives of the cardiac arrest victims.

Table 2 reveals that the primary reasons for CPR refusal primarily hinges on dispatching before receiving instructions. The inability to manage emotional distress while providing life-saving assistance also emerges as a significant factor, often stemming from close relatives, facing difficulties accessing the area to provide aid, or feeling too old or physically weak to perform CPR. Furthermore, it's noted that some bystanders refuse to perform CPR for multiple reasons.

The qualitative data about the reasons why the bystander did not perform CPR.

Difficulty in controlling their emotions

When there's a report of OHCA and the caller is overwhelmed by fear and concern, especially if the patient is a close relative, EMDs should exhibit patience, empathy, and support. They should listen attentively, understand the caller's emotional state, and gently guide them through the provided instructions, helping them regain composure.

Caller left the phone

After receiving the call, EMDs must take time to inquire about the incident location to accurately and promptly provide the rescue team with the coordinates to reach the scene. This is because the current system cannot identify the location of the caller, and some phone lines cannot record the caller's number. Consequently, callers may become frustrated, unwilling to wait for instructions, thinking it's a waste of time, and hastily decide to go to the scene themselves. Conversely, emergency response teams may waste more time and arrive late at the scene due to unclear location information, necessitating a callback to the caller to obtain clear coordinates. This results in further delays and increased tardiness in reaching emergency patients. As a result, more time is needed for inquiries, typically 30-40 seconds. This reflects the lack of understanding of the emergency medical system by callers and the expectation that EMDs will know the location automatically. Sometimes, calls originate from different districts, while the dispatched center is located in the main district of each province, complicating the process.

Caller refused CPR

Bystanders often hesitate to perform CPR due to a lack of confidence in their abilities and concerns about potentially harming the patient. In such instances, EMDs can provide invaluable assistance by offering guidance on CPR procedures. They may also enlist the help of individuals with CPR experience nearby, ensuring that the person assisting is both confident and physically capable of administering CPR effectively.

Lack of knowledge and experiences to evaluate agonal breathing

In many situations, it is commonly found that callers are unable to assess whether emergency patient is breathing abnormally or not, often responding that they are still breathing (33/134). As a result, EMDs may overlook guiding CPR and other emergency codes that do not imply OHCA until emergency response team arrives and assesses situation, leading to delayed initiation of CPR.

DISCUSSION

In this research, bystanders might opt out of administering CPR because of their lack of confidence and fear of causing harm to the patient, a sentiment echoed in analogous studies conducted in the USA.²⁰ Additional obstacles include panic and challenges associated with moving patients into a supine position, mirroring findings from a 2018 study.²¹ However, scoping reviews have revealed three primary categories of factors contributing to the reduced willingness to perform CPR: (1) personal factors such as emotional distress, panic, and hysteria; (2) CPR knowledge such as abnormal breathing recognition, lack of confidence; and (3) procedural issues.²²

Even though over half of individuals (52%) were administering CPR, this figure falls short in comparison to developed countries like the USA, where 75% of bystanders have performed CPR and more than 5.4 million individuals trained in CPR globally in 2019.^23,24 The perception of uncertainty regarding correctness persisted, as only 8.9% had received CPR training, suggesting that lack of prior training might lead to incorrect application. Therefore, the benefits of bystander CPR in enhancing survival rates in OHCA could be compromised by the poor quality of CPR.²⁵

The research revealed that OHCA predominantly takes place in domestic settings (82.5%), leading to family members being the primary bystanders in 72.5% of cases. Moreover, 52% of all OHCA cases received CPR administered by their relatives. Numerous studies corroborate the idea that family members are more inclined to initiate rescue efforts than non-relatives. Family members were more inclined to perform BCPR than strangers.²⁶ This aligns with a survey in China where respondents expressed a readiness to perform life-saving interventions like CPR for family members at a rate as high as 98.6%, whereas the willingness decreased significantly to 76.3% for non-family members.²⁷

The researchers believe that since the majority of bystanders have not received CPR training, they are unlikely to perform CPR correctly, both in terms of the rate and depth of chest compressions, which is consistent with the findings of the other study.²⁸ However, while collecting data via audiotape, it is not clear whether the CPR instructions given by the EMDs were followed accurately by the bystanders, and how they performed chest compressions.

CONCLUSION

The research identified several barriers impeding bystander CPR delivery, predominantly arising from knowledge and skill deficiencies among callers. The authors suggested that tackling these, alongside other procedural obstacles associated with emergency calls, could be addressed through public education campaigns. Future studies should explore experimentation among bystander groups lacking training but receiving CPR guidance to enhance CPR training and DA-CPR.

ACKNOWLEDGEMENTS

Authors would like to thank to emergency medical institute, in collaboration with the national research council of Thailand (NRCT). Additionally, extend gratitude to the faculty of medicine for their generous allocation of research time. Special thanks are also due to the data sources: the emergency medical dispatch centers of Maha Sarakham province, the emergency medical dispatch center of Chao Phraya Abhaibhubejhr hospital in Prachinburi Province, and the emergency medical dispatch center of Songkhla provincial administrative organization.

Funding: The emergency medical institute, in collaboration with the National Research Council of Thailand (NRCT)

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Lim SL, Smith K, Dyson K, Chan SP, Earnest A, Nair R, et al. Incidence and Outcomes of Out-of-Hospital Cardiac Arrest in Singapore and Victoria: A Collaborative Study. J Am Heart Assoc. 2020;9(21):e015981.
2. 2. Shin SD, Ong MEH, Tanaka H, Ma MHM. Comparison of Emergency Medical Services Systems Across Pan-Asian Countries: A Web-based Survey. Prehospital Emergency Care. 2012;16(4):477-96.
3. 3. Ong ME, Shin SD, De Souza NN, Hideharu T, Tatsuya N, Kyoung JS, et al. Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS). Resuscitation. 2015;96:100-8.
4. 4. Sirikul W, Piankusol C, Wittayachamnankul B, Riyapan S, Supasaovapak J, Wongtanasarasin W, et al. A retrospective multi-centre cohort study: Prehospital survival factors of out-of-hospital cardiac arrest (OHCA) patients in Thailand. Resuscitation Plus. 2022;9:100196.
5. 5. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the" chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation. 1991;83(5):1832-47.
6. 6. Nolan J, Soar J, Eikeland H. The chain of survival. Resuscitation. 2006;71(3):270-1.
7. 7. Cummins RO, Eisenberg MS, Hallstrom AP, Litwin PE. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emergency Med. 1985;3(2):114-9.
8. 8. Nikolaou N, Dainty KN, Couper K, Morley P, Tijssen J, Vaillancourt C, et al. A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children. Resuscitation. 2019;138:82-105.
9. 9. Smith CM. Improving public-access automated external defibrillator use in a volunteer first-responder system for out-of-hospital cardiac arrest (Doctoral dissertation, University of Warwick). 2020.
10. 10. Olasveengen TM, Mancini ME, Perkins GD, Suzanne A, Steven B, Maaret C, et al. Adult Basic Life Support Collaborators. Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020;156:35-79.
11. 11. Riyapan S, Saengsung P, Chantanakomes J, Nakornchai T, Limsuwat C. Impact of the motorcycle-taxi cardiopulmonary resuscitation (CPR) project on bystander CPR in the Bangkoknoi district of Bangkok, Thailand. Resuscitation. 2021;162:180-1.
12. 12. Yeeheng U, Rawiworrakul T. Bystander Cardio-Pulmonary Resuscitation Practice among Out-of-Hospital Cardiac Arrest: Rajavithi Hospital’s Narenthorn Emergency Medical Service Center, Thailand. J Publ Heal. 2018;48(2):256-69.
13. 13. Eiamla-or P, Takan S, Wongsasung J, Nunchai K. Effectiveness of Basic Life Support Short Course Training Among Thai Vocational College Students. Human Behav Develop Society. 2023;24(3):19-27.
14. 14. Tippayanate NW, Phrom KC, Boonrueang WC. Comparing the effectiveness of cardiopulmonary resuscitation training at the basic level using video and traditional training methods among high school students in Mahasarakham Province. J Sci Technol. 2018;37(4).
15. 15. Khunsawai B, Promarak T, Tippayanate N. The effects of the SMART SAFE program on the basic life support competency of community health volunteers in Tha Tad Cheung Chum Subdistrict, Mueang District, Sakon Nakhon Province. J Publ Heal Res. 2020;9(2):69-79.
16. 16. Angkoontassaneeyarat C, Yuksen C, Jenpanitpong C, Rukthai P, Seanpan M, Pongprajak D, et al. Effectiveness of a dispatcher-assisted cardiopulmonary resuscitation program developed by the Thailand National Institute of Emergency Medicine (NIEMS). Prehospital Disaster Med. 2021;36(6):702-7.
17. 17. Tippayanate N, Phonkanya P, Neungkantee K, Neungkantee K, Raksapakdee K, Boonnop W, et al. Enhancing the detection of out-of-hospital cardiac arrest: a study of emergency medical system in Thailand. Int J Community Med Public Health. 2023;10(10):3490-95.
18. 18. Astuti Z, Jannah MN. The Willingness of Bystander to Perform CPR to the Patient with Out of Hospital Cardiac Arrest During the Pandemic COVID-19: A Literature Review. Int Conference Nursing Health Sci. 2021;2(2):67-74.
19. 19. Ong MEH, Cho J, Ma MHM, Tanaka H, Nishiuchi T, Al Sakaf O, et al. Comparison of emergency medical services systems in the Pan-Asian Resuscitation Outcomes Study countries: Report from a literature review and survey. Emergency Med Aust. 2013;25(1):55-63.
20. 20. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR‐trained bystanders perform CPR? Academic Emergency Med. 2006;13(6):596-601.
21. 21. Case R, Cartledge S, Siedenburg J, Smith K, Straney L, Barger B, Finn J, Bray JE. Identifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: A qualitative review of emergency calls. Resuscitation. 2018;129:43-7.
22. 22. Matsuyama T, Andrea S, Tommaso P, Robert G, Taku I. Willingness to perform bystander cardiopulmonary resuscitation: A scoping review. Resuscitation Plus. 2020;4:100043.
23. 23. Chocron R, Jobe J, Guan S, Kim M, Shigemura M, Fahrenbruch C, et al. Bystander cardiopulmonary resuscitation quality: potential for improvements in cardiac arrest resuscitation. J Am Heart Assoc. 2021;10(6):e017930.
24. 24. Böttiger BW, Lockey A, Aickin R, Carmona M, Cassan P, Castrén M, et al. Up to 206 million people reached and over 5.4 million trained in cardiopulmonary resuscitation worldwide: the 2019 International Liaison Committee on Resuscitation World Restart a Heart Initiative. J Am Heart Assoc. 2020;9(15):e017230.
25. 25. Lund-Kordahl I, Maria M, Jørgen M, Theresa MO, Kjetil S, Knut F. Relationship between level of CPR training, self-reported skills, and actual manikin test performance-an observational study. Int J Emergency Med. 2019;12(1):1-8.
26. 26. Chang YH, Kwak SD, Shin YS, Ro DK. Characteristics of bystander cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrests: a national observational study from 2012 to 2014. Resuscitation. 2017;211:26-33,
27. 27. Chen M, Wang Y, Li X, Hou L, Wang Y, Liu J, et al. Public knowledge and attitudes towards bystander cardiopulmonary resuscitation in China. BioMed Res Int. 2017;2017:3250485..
28. 28. Fang-Yu L, Kun-Chang L, Chian-Shiu C, Wan-Ting H, Yi-Ying L, Yi-Ping Y, et al. The impact of bystander cardiopulmonary resuscitation on patients with out-of-hospital cardiac arrests. J Chinese Med Assoc. 2021;84(12):1078-83.