Clinical paperIdentifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: A qualitative review of emergency calls☆
Introduction
The delivery of bystander cardiopulmonary resuscitation (CPR) is a crucial element in the chain of survival for out of hospital cardiac arrest (OHCA) [1]. Following landmark trials [2,3], some communities have managed to overcome certain barriers to bystanders providing CPR through the introduction of CPR instructions in the emergency call (dispatcher-assisted CPR, DA-CPR) and the prioritisation of chest compressions over mouth-to mouth breaths [[4], [5], [6]]. However, there is still significant room for improvement, with large registries reporting suboptimal CPR rates [7,8] and emerging evidence of significant regional variation in bystander CPR rates across units as small as “neighbourhoods” [9,10].
International bodies have suggested that targeting these “high-risk neighbourhoods” (i.e. regions with low bystander CPR and high OHCA incidence) with community-based interventions is a cost-effective way of improving bystander CPR rates and may have the greatest capacity to improve patient survival [11]. However, before such interventions can take place, further information is required to understand why this regional variation is occurring, including the possibility that the barriers to the residents performing bystander CPR in these regions are different.
Most research to date has focussed on identifying these ‘low bystander-CPR” regions and understanding differences in the underlying demographics of the populations [[12], [13], [14]]. In the present study, we listened to emergency calls from regions with low bystander CPR with the aim of identifying why bystander CPR is not provided during calls where OHCA is recognised and in a system where DA-CPR is available.
Section snippets
Study design, setting and EMS system
We conducted a retrospective review of de-identified recordings of emergency calls for adult patients suffering an OHCA within ten local government areas in the Australian state of Victoria that were previously [10] ranked as having the lowest rates of bystander CPR.
Ambulance Victoria is the sole provider of emergency ambulance services in this state (2015 population = 5,966,700). All emergency medical calls in Victoria are directed to Ambulance Victoria through the Emergency Services
Sample
Over the study period, there were 1423 adult OHCA of presumed cardiac aetiology (not EMS witnessed) in the ten identified regions – of whom OHCA was identified by the caller-taker in 88.1% (n = 1253). Of these cases, excluding 174 cases classified as obvious deaths, 515 (48.4%) were documented as receiving bystander CPR, 418 (39.2%) as not receiving bystander CPR and in 132 (12.4%) patients’ bystander CPR status was unknown.
We reviewed all calls with unknown bystander CPR status, and found in
Discussion
Our study is the first study to use emergency calls to 1) identify barriers to the provision of bystander CPR in Australia and 2) to focus specifically on regions with low bystander CPR. Through a thematic analysis of recorded OHCA calls to EMS we identified three main barriers to bystanders providing CPR: procedural issues, lack of CPR knowledge and personal factors. Some of these barriers have been identified previously: proximity to the patient, delayed recognition of OHCA, physical
Acknowledgements
This study is supported by an Australian National Heart Foundation (NHF) Vanguard grant (#101048). JEB is supported by a NHF Future Leader Fellowship. RC, SC, LS and JF and JEB received support from the NHMRC Centre of Research Excellence: the Australian Resuscitation Outcomes Consortium (Aus-ROC) (#1029983).
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.06.001.