Life Saving Emergency Medical Dispatch and Pre-Hospital Care Improvements in Rhode Island
In Rhode Island an estimated 1 in 10 people who have an out of hospital cardiac arrest survive. In other states, the chances of survival are much better1,2,3.
It’s time to improve our system and save lives.
On average, 130,000 Rhode Islanders call 9-1-1 for medical assistance every year4. A call triggers a response in the EMS system, sending qualified medical providers and ambulances to provide assistance and transport. In most 9-1-1 systems nationwide, the 9-1-1 operators go on to provide instructions to the caller. But not in Rhode Island. These “pre-arrival instructions,” when provided by certified Emergency Medical Dispatchers (EMDs) have been proven safe, effective, and lifesaving5,6.
Pre-arrival 9-1-1 instructions are standard across the nation7,8.
Trained 9-1-1 operators coach people through immediate measures such as CPR (known as telecommunicator CPR or T-CPR). They give instructions for other emergencies like bleeding control, choking, or assistance for drug overdose victims, meanwhile collecting key information for emergency responders prior to their arrival. In fact, T-CPR has been included in the American Heart Association guidelines for resuscitation care since 2010, and has been graded as the highest level (Class I) recommendation in the most recent 2017 guidelines9,10.
In Rhode Island, no such system exists.
Instead, victims are at the mercy of bystanders, often family or friends, until the trained providers arrive. In the urban setting, this takes an average of 6 minutes11. The wait can be longer in extenuating circumstances, such as a snowstorm or difficult to reach house. To a victim whose heart or breathing has stopped, 5 minutes without oxygen is long enough to cause irreversible, often fatal, brain damage. With dispatcher instructions, we can save lives by giving bystanders the ability to provide care.
Five minutes without oxygen is too long. We have to do better.
Every year about 1000 Rhode Islanders experience a sudden cardiac arrest outside of the hospital12,13. That’s 3 every day! Of these, an estimated 25 - 50% are due to a treatable arrhythmia like ventricular fibrillation (VF)9,13. Rhode Island is missing one key factor in the chain of survival: early bystander CPR. Bystander CPR “slows the dying process” and gives the victim a fighting chance at survival14.
Studies have shown that bystander CPR increases rates of survival by over 200% in OHCA5,15. Though most Americans are familiar with CPR16, rates of bystander CPR remain very low17. In a recent pilot study of OHCA in Rhode Island, bystander CPR was performed in only 20% of cases18. T-CPR pre-arrival instructions have been shown to double the rates of bystander CPR19 and are nearly as effective as CPR provided by a trained medical professional6,20,21.
It’s worth saying again. Bystander CPR improves chance of survival 200%.
It doesn’t stop there. Survival from OHCA requires complex systems of care and chain of survival that begins with early access to CPR and an Automatic Defibrillator (AED), continued with robust prehospital management of cardiac arrest and care at the hospital9,22. Dispatcher assisted bystander CPR has been proven to improve survival especially when integrated with other links in the chain like AED use, more CPR education and advanced systems of care6,19,21,22.
Across the country, from Rochester to Seattle, communities have dramatically increased their cardiac arrest survival rate with programs that include dispatcher-assisted CPR. Arizona now has an overall survival rate of 35% for VF cardiac arrest3. In Rochester, victims of witnessed VF arrest have a 50% chance of survival2. In Seattle/King County WA the survival rate for witnessed VF arrest is 62%1... that translates to hundreds of saved lives every year. Currently, Rhode Islanders who suffer from OHCA are lucky to have a 1 in 10 chance of survival9.
This is unacceptable.
Our EMS crews and hospitals already provide excellent care, but this is just one link in the chain, and more needs to be done. Unfortunately, even 5 minutes without oxygen can be deadly. Even the fastest EMS response sometimes arrive too late. Bystander CPR is crucial. When 9-1-1 is called, an opportunity exists not just to send help, but to utilize the caller to provide immediate, life-saving aid. Think of 9-1-1 dispatchers as the “first” first responders, not simply telephone operators. With pre-arrival instructions a, including T-CPR, and strengthening the links in the chain, these first few crucial minutes can be a life-saving opportunity to do something.
We are asking the State of Rhode Island to:
Restore full staffing implement for 911 operations centers
Restrict and use e911 tax-supported and federal funds for 911 operations and related pre-hospital care separate from professional EMS services.
Take immediate action to institute Emergency Medical Dispatch including T-CPR by training dispatchers using a nationally recognized curriculum.
Institute physician led, medical oversight of Emergency Medical Dispatch, including quality assurance, call review, and participation in a national registry of cardiac arrest data.
Continue to recommend investments in evidence based, proven investments to pre-hospital care that includes training, equipment, and technology enhancements as determined by an oversight committee.
The very lives of our residents and loved ones depend on it.
Catherine Cummings, MD
Rhode Island Chapter, American College of Emergency Physicians
Joseph R. Lauro, MD
RI ACEP - Emergency Medical Services Committee
Steven R. DeToy
Director of Government and Public Affairs
Rhode Island Medical Society
Kings County Division of Emergency Services. 2017 annual report; 2017; 69. Available online at https://www.kingcounty.gov/depts/health/~/media/depts/health/emergency-medical-services/documents/reports/2017-Annual-Report.ashx
Okubu M, Atkinson EJ, Hess EP, White RD. Improving trend in ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest in Rochester, Minnesota: A 26-year observational study from 1991 to 2016. Resuscitation. 2017;120:31-37.
Spaite, Daniel W. et al. Statewide regionalization of postarrest care for out-of-hospital cardiac arrest: association with survival and neurologic outcome. Annals of Emerg Med. 2014;64(5),496-506.
State of Rhode Island and Providence Plantations. Rhode Island Department of Public Safety: E-9-1-1 Uniform Emergency Telephone System 2016 call volume report. Public report accessed on 2/21/2018 at http://ri911.ri.gov/documents/2016stats.pdf
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003;107:2780–2785.
Bobrow BJ, Eisenberg MS, Panczyk M. Telecommunicator CPR: pushing for performance standards. Prehosp Emerg Care. 2014;18:558–559
Yancey A & Clawson JJ. EMD position paper resource document. Annals of Emerg Dispatch and Response. 2014;2(2).
National Association of EMS Physicians. Position paper on emergency medical dispatch. Prehospital Emerg Care. 2008;12:217.
Lerner EB et al. Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2012;125(4):648-55.
Kleinman ME, Goldberger ZD, Rea T, Swor RA, Bobrow BJ, Brennan EE, Terry M, Hemphill R, Gazmuri RJ, Hazinski MF, Travers AH. 2017 American Heart Association focused update on adult basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2018;137(1). http://circ.ahajournals.org/content/circulationaha/early/2017/11/06/CIR.0000000000000539.full.pdf
Mell HK et al. Emergency medical services response times in rural, suburban, and urban areas. JAMA Surg. 2017 Jul 19; [e-pub].
Benjamin EJ et al. Heart disease and stroke statistics-2018 Update. Circulation. 2018;137(11). Epublished ahead of print at http://circ.ahajournals.org/content/early/2018/01/30/CIR.0000000000000558
Go AS, Mozaffarian D, et al. Heart Disease and Stroke Statistics-2014 update: A report from the American Heart Association. Circulation. 2014;129(3):e280e292
American Heart Association. Cardiac arrest doesn’t have to be a death sentence. AHA news. June 3, 2015. Available at https://news.heart.org/cardiac-arrest-doesnt-have-to-be-death-sentence/
Hopkins CL, Burk C, Moser S, Meersman J, Baldwin C, Youngquist ST. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc. 2016;5(1).
Clawson A, Stewart P, Olola C, Freitag S, Clawson J. Public expectations of receiving telephone pre-arrival iInstructions from emergency medical dispatchers at 30 years post origination. Journal of Emergency Dispatch. 2011; 13(3),34-39.
Sasson C, Rogers MA, Dahl J, Kellerman AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63-81.
Thorndike J, Asselin N. The effects of a new 30-minute CPR protocol on out of hospital cardiac arrest in RI. Unpublished manuscript. Department of Emergency Medicine, Division of Emergency Medical Services, Alpert Medical School of Brown University. 2018.
Vaillancourt C, Verma A, Trickett J, Crete D, Beaudoin T, Nesbitt L, Wells GA, Stiell IG. Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions. Acad Emerg Med. 2007; 14: 877–883
Kellermann AL, Hackmann BB, Somes G. Dispatcher-assisted cardiopulmonary resuscitation. Validation of efficacy. Circulation. 1989; 80:1231-1239.
Bohm K, Stalhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J, Svensson L. Tuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR. Resuscitation. 2009; 80: 1025–1028.
McCarthy JJ, Carr B, Sasson C, Bobrow BJ, Callaway CW, Neumar RW, Ferrer JME, Garvey JL, Ornato JP, Gonzales L, Granger CB, Kleinman ME, Bjerke C, Nichol G. Out-of-Hospital cardiac arrest resuscitation systems of care: A scientific statement from the American Heart Association. Circulation.
Rhode Island Chapter, American College of Emergency Physicians
Rhode Island Medical Society