A Mixed Methods Investigation of Out of Hospital Cardiac Arrests Calls and Telephone Assisted Cardiopulmonary Resuscitation to Improve Cardiopulmonary Resuscitation Performance in Saudi Arabia

Abstract

Out of hospital cardiac arrest (OHCA) is a global health problem with a survival rate of only 7-10%. Prompt and high-quality cardiopulmonary resuscitation (CPR) has the potential to improve survival rate. Whilst the use of telephone CPR (T-CPR) protocols by emergency medical service (EMS) dispatchers can improve the quality of CPR, they are still below international resuscitation recommendations for performance standards. Improving the language (e.g., the clarity and simplicity of choice of words) of T-CPR protocols is a modifiable factor that is likely to improve CPR performance. However, it is unclear how to improve it due to the lack of detailed investigation. OHCA studies performed in Saudi Arabia are limited but evidence suggests low rates of survival (5%). T-CPR is currently implemented in Saudi Arabia but its efficacy has not been investigated. This project was undertaken with the aim of improving CPR timeliness and quality by investigating the nature of OHCA calls and the T-CPR protocol in current practice in Saudi Arabia and evaluating the impact of modified T-CPR instructions. A sequential mixed methods design was conducted, and included a retrospective observation of OHCA call recordings, followed by before-after simulation study to test a modified set of T-CPR instructions (that focused on enhancing the protocol by simplifying the language used in the instructions). A sample of 100 OHCA calls made to the main EMS in Riyadh, Saudi Arabia were reviewed and characterised both quantitatively and qualitatively. The ‘before’ component of the simulation study evaluated CPR performance of 50 participants using the current Saudi T-CPR protocol and investigated how language (e.g., word choices and phrases) might influence performance and how it can be improved. Data recorded included quantitative measures relating to the quality of CPR delivered during the simulation and semi structured interviews to explore participants’ experiences of the T-CPR protocol. An enhanced protocol was then developed based on findings from the observation of calls study and the ‘before’ component of the simulation study, as well as drawing on evidence from literature. Modifications included simplifying the T-CPR language to ‘plain’ language (e.g., using simple, precise, and concise terms and avoiding anatomical terms). The timeliness and quality of CPR performance while following the enhanced protocol was then evaluated in a separate sample 50 participants; the ‘after’ component of the simulation study. Observation of calls identified low return of spontaneous circulation (ROSC) in current practice (10%). This low ROSC could be attributed in part to the prolonged time to starting chest compression by callers, with a median of 367 s (IQR 266.75–550.5) from EMS call receipt, which is below the resuscitation recommendation (by 217 s). A further observation of the calls identified a number of opportunities to save time compared with current T-CPR protocol. For example, where instructions lacked precision and used local dialect languages resulting in the need for further clarification. The use of the enhanced T-CPR protocol in the simulation study demonstrated a reduced median time to first compression from 110 (IQR 99.75-125.5) to 79 s (IQR 69 – 89.25), depth of compression was improved from 30 to 35 mm and did the chest compression rate from 94.5 to 105 compressions per minute. Participants that took part in qualitative interviews reported that the instructions given in the enhanced protocol were easier to understand and interpret compared with the language used in the current Saudi Arabian protocol. Improvements using the enhanced protocol is attributed to using the simplified ‘plain’ language. This study contributes to the current literature by providing detailed investigation of factors that could possibly explain why time to first compression currently falls so far short of international guidelines. It is also the first study to investigate the characteristics of OHCA calls and T-CPR protocol in current practice in Saudi Arabia. It is also the first study to provide detailed investigation to how T-CPR language could be improved aiming to improve CPR performance. It might be hoped that by optimising language used in the T-CPR protocol, improvements in CPR timeliness and quality might improve survival rate.

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Identifiers

ORCID for Graham Petley: orcid.org/0000-0002-3295-0444

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