Elsevier

Resuscitation

Volume 188, July 2023, 109816
Resuscitation

Clinical paper
Association between bystander physical limitations, delays in chest compression during telecommunicator-assisted cardiopulmonary resuscitation, and outcome after out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2023.109816Get rights and content

Abstract

Background

Promptly initiated bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA). Many OHCA patients require repositioning to a firm surface. We examined the association between repositioning, chest compression (CC) delay, and patient outcomes.

Methods

We used a quality improvement registry from review of 9-1-1 dispatch audio recordings of OHCA among adults eligible for telecommunicator-assisted CPR (T-CPR) between 2013 and 2021. OHCA was categorized into 3 groups: CC not delayed, CC delayed due to bystander physical limitations to reposition the patient, or CC delayed for other (non-physical) reasons. The primary outcome was the repositioning interval, defined as the interval between the start of positioning instructions and CC onset. We used logistic regression to assess the odds ratio of survival according to CPR group, adjusting for potential confounders.

Results

Of the 3,482 OHCA patients eligible for T-CPR, CPR was not delayed in 1,223 (35%), delayed due to repositioning in 1,413 (41%), and delayed for other reasons in 846 (24%). The repositioning interval was longest for the physical limitation delay group (137 secs, IQR-148) compared to the other delay group (81 secs, IQR-70) and the no delay group (51 secs, IQR-32) (p < 0.001). Unadjusted survival was lowest in the physical limitation delay group (11%) versus the no delay (17%) and other delay (19%) groups and persisted after adjustment (p = 0.009).

Conclusion

Bystander physical limitations are a common barrier to repositioning patients to begin CPR and are associated with lower likelihood of receiving CPR, longer times to begin CC, and lower survival.

Introduction

Promptly initiated cardiopulmonary resuscitation (CPR) increases the chance of survival from out-of-hospital cardiac arrest (OHCA).1 Telecommunicator-assisted CPR (T-CPR), also known as telephone-CPR, provides just-in-time instructions to a bystander to help initiate CPR. This strategy improves both the likelihood that an individual suffering an OHCA receives bystander CPR and the chance of survival compared with those who do not receive bystander CPR.1 CPR is time-dependent with the likelihood of survival declining with every minute of delay.2, 3 Early bystander CPR is especially a challenge in the home setting where the majority of OHCAs occur.4 Based on the registry from the Resuscitation Outcome Consortium, only 35% of persons receive bystander CPR when OHCA occurs in the home where survival is 6%.5 In contrast, bystander CPR is provided in 44% of public-setting OHCAs, where survival is 16%.5 Understanding and addressing the challenges that bystanders encounter responding to OHCA especially in the home is important to improving survival.

Current guidelines recommend repositioning the OHCA patient from a soft surface (e.g. bed, sofa) to a firm, flat surface for CPR with the goal to improve chest compression (CC) quality.6 Guidelines note that it is possible to deliver effective compressions on a soft surface if rescuers compensate for the mattress compression.6, 7 Repositioning is a common barrier to T-CPR.8, 9, 10, 11 Although research has examined delays to bystander CCs, little is known about the time-dependent relationship involving repositioning barriers.10 Current guidelines do not specify alternative strategies or timelines to consider other approaches such as accommodating CCs being performed without repositioning the patient.6 Research using simulation and manikins in healthcare settings suggests that repositioning to the floor may not improve compression depth, providing some support to consider performing CPR “as is” when repositioning is challenged.12 Additional research is needed to understand the tradeoff between time delay directly attributable to repositioning and the potential increase in compression depth (if any) afforded by the firm surface. Such an understanding could be the basis for providing recommendations to telecommunicators for when efforts to reposition should cease and CCs on a soft surface be initiated.

The purpose of this study was to evaluate how physical limitation related to the outcome of time required to reposition a patient to begin CPR, understanding that delays to early CPR adversely affect the chances of survival. We also evaluated how delay groups were associated with process outcomes of bystander CPR provision, and the clinical outcomes of survival and survival with good neurologic function.

Section snippets

Study design, population, and setting

We conducted a retrospective cohort investigation using a quality improvement registry of OHCA in adults eligible for T-CPR in a US metropolitan region between 2013 and 2021. We excluded cases that did not have a 9-1-1 recording available, where CPR was ongoing at the start of the call or at an unknown time, arrests that occurred after the 9-1-1 call and before EMS arrival, or if T-CPR instructions were not provided. In the study community, emergency medical response is activated by calling

Results

During the nine-year period, 7,626 adult patients had OHCA at the time of the 9-1-1 call. Of these, 4,144 were excluded: 418 due to unavailable 9-1-1 recording, 2,307 due to CPR initiation before the call, 1,074 because the arrest occurred after the 9-1-1 call was completed, 237 because T-CPR instructions were not provided, and 108 due to the 9-1-1 call ending prematurely, leaving a final sample of 3,482 OHCA patients eligible for T-CPR (Fig. 1). The telecommunicator recognized the OHCA in 94%

Discussion

In this large cohort study of OHCA in adults eligible for T-CPR, we observed that patients experienced the longest delay to first CC and the lowest survival when bystanders encountered challenges repositioning the patient to supine and on a firm surface for CPR. In our sample, we found that physical limitations which prevented repositioning the patient occurred in 41% of T-CPR-eligible OHCA calls. This Physical Delay group experienced a median repositioning interval of 137 seconds before

Limitations

This study had several limitations. We conducted a retrospective investigation that used quality improvement data. The data was not prospectively collected specifically for study purposes and did not contain all the data elements that might have been helpful for this research, such as the initial precise location (e.g., bed) of the patient at the time or arrest. The study community also had a mature dispatch program that prioritizes quality improvement efforts involving OHCA identification and

Conclusion

Bystander physical limitation is a common barrier to repositioning patients to begin CPR. Repositioning delays were associated with lower likelihood of receiving bystander CPR, longer times to CC initiation, lower survival to hospital discharge and lower survival with good neurologic function. The results suggest there may be a time point when efforts aimed at repositioning have a diminishing return and a potential alternative could be CPR in the “as-is” position even if this position is a soft

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Robert Neumar reports financial support was provided by American Heart Association. Thomas Rea reports financial support was provided by American Heart Association. Amanda Missel reports financial support was provided by National Institutes of Health. Amanda Missel reports financial support was provided by American Heart Association.

Acknowledgements

This work was supported by awards from the American Heart Association Grant #19SFRN34760762/Neumar/2019 and Grant #19SFRN34830063/Sotoodehnia/2019; and by Grant #T32-HL007853 from the NIH. The study sponsors were not involved in the study design, collection of data, analysis, and interpretation of data, or in the writing or submission of the manuscript.

Research Elements

Use of the data resource requires collaboration with the investigators and implementation of a data use agreement.

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