Dallas 2015 TFQO: Maaret Castrén #320 EVREV 1: Christian Vaillancourt #416 EVREV 2: Michael Sayre #400 Taskforce: BLS BLS 359: Dispatcher Instructions

Dallas 2015 COI Disclosure (SPECIFIC to this systematic review) EVREV 1 COI#416 Commercial/industry none Potential intellectual conflicts Received non-commercial peer-reviewed funding and authored one of the included paper EVREV 2 COI#400 Commercial/industry none Potential intellectual conflicts none

Dallas Treatment Recommendation Bystanders who call their local emergency response number should receive initial instructions on performing CPR. Dispatchers should assertively provide compression-only CPR instructions to untrained rescuers for adults with suspected OHCA without any delay. If dispatchers suspect asphyxial arrest, it is reasonable to provide instructions on rescue breathing followed by chest compressions. When performing quality improvement efforts, it is reasonable to assess the accuracy and timeliness of dispatcher recognition of cardiac arrest and the delivery of CPR instructions.

Dallas 2015 C2015 PICO Population: Among adults and children who are in cardiac arrest outside of a hospital Intervention: does the ability of a dispatch system to provide CPR instructions Comparison: compared with a dispatch system where no CPR instruction are ever provided Outcomes: change…

Dallas 2015 C2015 PICO Outcomes: -Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year9-Critical -Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year8-Critical -ROSC7-Critical -Delivery of bystander CPR5-Important -Time to commence CPR5-Important -CPR parameters (VF/VT)5-Important

Dallas 2015 Inclusion/Exclusion & Articles Found Included Comparative studies reporting on dispatcher- assisted cardiopulmonary resuscitation for adult and pediatric cardiac arrest. Excluded Unpublished studies or only published in abstract form, manikin, and animal studies. Search identified 308 studies We included 14 (3 RCTs, 6 before-after, 5 cohort studies)

Dallas Proposed Treatment Recommendations We recommend that dispatchers should provide CPR instructions to callers in order to improve survival from OHCA. (serious indirectness, strong recommendation, low quality of evidence). We recommend that dispatchers should provide CPR instructions to callers in order to improve bystander CPR rates. (some indirectness, strong recommendation, low to very low quality of evidence).

Dallas 2015 Risk of Bias in studies RCT bias assessment StudyYearDesign Total Patients Population Industry Funding Allocation: Generation Allocation: Concealment Blinding: Participants Blinding: Assessors Outcome: Complete Outcome: Selective Other Bias Hallstrom 2000RCT520OHCANoUnclearLowHighLowHighLow Rea 2010RCT1,941OHCANoLow HighLow Svensson 2010RCT1,276OHCAUnclearLow HighUnclearHighLow

Dallas 2015 Risk of Bias in studies Non-RCT bias assesment StudyYearDesign Total Patients Population Industry Funding Eligibility Criteria Exposure/ Outcome Confounding Follow up Akane 2012Cohort1,780Any P-OHCANoHighUnclearHighLow Bang 1999Cohort473OHCANoHighLowHighLow Bray 2011Before-after3,122OHCANoLow Culley 1991Before-after6,918VF/VT OHCANoLow High Eisenberg 1985Before-after446OHCANoLow High Kuisma 2005Cohort373VF/VT OHCANoLow HighLow Rea 2001Cohort7,265OHCANoLow Stipulante 2014Before-after600OHCANoLow HighLow Tanaka 2012Before-after4,995OHCANoUnclear HighUnclear Vaillancourt 2007Before-after529OHCANoLow HighLow Van Vleet 2012Cohort778OHCANoHighUnclearHighLow

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Proposed Consensus on Science statements For the critical outcome of survival with favourable neurological outcome, we have identified low to very low quality evidence from two RCTs, (one reported outcomes at hospital discharge, downgraded for indirectness and imprecision [Rea 2010, 423]), the other at end-of-study, downgraded for risk of bias, indirectness and imprecision [Hallstrom 2000, 190]). We also identified one cohort study (outcome at 30 days, downgraded for risk of bias and imprecision [Akahane 2012, 1410]), and one before-after study (outcome at one year, downgraded for risk of bias, indirectness and imprecision [Tanaka 2012, 1235]). All studies reported a benefit which was not statistically significant.

Dallas 2015 Proposed Consensus on Science statements For the critical outcome of survival, we have identified low to very low quality evidence from three RCTs (one reporting outcomes at one day, 30 days, and hospital discharge, downgraded for risk of bias, indirectness and imprecision [Svensson 2010, 434]; one to hospital admission and hospital discharge, downgraded for risk of bias, indirectness and imprecision [Hallstrom 2000, 190]; and one to hospital discharge only, downgraded for indirectness and imprecision [Rea 2010, 423]). Hüpfl [2010, 1552] meta-analyzed the three RCTs (low quality, downgraded for risk of bias and indirectness) and found an absolute survival benefit of 2.4% (95%CI 0.1%-4.9%) in favour of continuous chest compressions over traditional CPR [NNT 41; (95%CI 20- 1,250); RR 1.22 (95%CI )].

Dallas 2015 Proposed Consensus on Science statements We also identified five before-after studies (three reporting outcomes at hospital admission, downgraded for inconsistency, indirectness and imprecision [Bray 2011, 1393, Stipulante 2014, 177, and Vaillancourt 2007, 877], four at hospital discharge, downgraded for risk of bias, inconsistency, indirectness and imprecision [Bray 2011, 1393, Culley 1991, 362, Eisenberg 1985, 47, and Vaillancourt 2007, 877], and one at one year, downgraded for risk of bias, indirectness and imprecision [Tanaka 2012, 1235]). The study by Vaillancourt 2007, 877 was inconsistent with the others and found decreased survival, but was not powered to evaluate survival outcomes. The study by Tanaka 2012, 1235 showed a survival benefit at one year (population of 73 patients) from an educational program for dispatchers on CCC and agonal breathing [Adj. OR 1.81 (95%CI )].

Dallas 2015 Proposed Consensus on Science statements We also identified four cohort studies (three reporting outcomes at hospital discharge, downgraded for risk of bias, inconsistency, indirectness and imprecision [Bang 1999, 175; Kuisma 2005, 89; and Rea 2001, 2513], and one at 30 days, downgraded for risk of bias and indirectness [Akahane 2012, 1410]). That study by Akahane 2012, 1410 showed a survival benefit at 30 days when T-CPR was provided to a pediatric OHCA population vs. not after an educational program [Adj. OR 1.46 (95%CI )].

Dallas 2015 Proposed Consensus on Science statements For the critical outcome of ROSC, we have identified low to very low quality evidence from one RCTs, downgraded for indirectness and imprecision [Rea 2010, 423], and one before-after study, downgraded for imprecision [Vaillancourt 2007, 877]. Both studies reported a benefit which was not statistically significant.

Dallas 2015 Proposed Consensus on Science statements For the important outcome of delivery of bystander CPR, we have identified low to very low quality evidence from six before-after studies, downgraded for risk of bias, inconsistency and indirectness, and one cohort study, downgraded for risk of bias and imprecision. All showed a strong association between the studied intervention and bystander CPR. The cohort study [Akahane 2012, 1410] showed increased performed chest compressions [Adj. OR 6.04 (95%CI )] and ventilations [Adj. OR 3.10 (95%CI )] from T-CPR, and an absolute increase in bystander CPR rate of 40.9% (95%CI 36.1 to 45.5). [Bray 2011, 1393] studied two MPDS versions, [Culley 1991, 362; Eisenberg 1985, 47; and Vaillancourt 2007, 877] studied T- CPR vs. not, and [Stipulante 2014, 177 and Tanaka 2012, 1235] each studied various educational programs.

Dallas 2015 Proposed Consensus on Science statements For the important outcome of time to commence CPR, we have identified very low quality evidence from four before-after studies, downgraded for risk of bias, inconsistency, indirectness and imprecision [Culley 1991, 362; Eisenberg 1985, 47; Stipulante 2014, 177; and Tanaka 2012, 1235], and one cohort study, downgraded for risk of bias, indirectness and imprecision [Rea 2001, 2513], none of which reported a statistically significant

Dallas 2015 Proposed Consensus on Science statements For the important outcome of CPR parameter (assessed with initial rhythm of VF/VT), we have identified very low quality evidence from one RCT, downgraded for risk of bias, indirectness and imprecision [Svensson 2010, 434], and one before-after study, downgraded for imprecision [Vaillancourt 2007, 877]. All studies reported a benefit which was not statistically significant.

Dallas Proposed Treatment Recommendations We recommend that dispatchers should provide CPR instructions to callers in order to improve survival from OHCA. (serious indirectness, strong recommendation, low quality of evidence). We recommend that dispatchers should provide CPR instructions to callers in order to improve bystander CPR rates. (some indirectness, strong recommendation, low to very low quality of evidence).

Dallas Values and Preferences Statement We recognize that the evidence in support of these recommendations comes from randomized and observational data of variable quality. However, the available evidence consistently favors telephone CPR protocols using a compression-only CPR instruction set. This suggests a “dose effect” e.g. quick telephone instructions in chest compression result in more compressions and faster administration to the patient.

Dallas Values and Preferences Statement In making these recommendations, we placed a higher value on the initiation of bystanded CPR and a lower value on the harms of performing CPR on patients who are not in cardiac arrest.

Dallas Knowledge Gaps What is the optimal instruction sequence for coaching callers in telephone CPR? What is the impact of telephone CPR instructions on non-cardiac etiology arrests? What is the impact of the dispatchers’ background (non-health care professional vs. paramedic or nurse)? What are the time-interval benchmarks for the completion of each step in the instruction process (transfer to ambulance dispatch, cardiac arrest recognition, dispatch of resources, initiation of instructions, etc.)?

Dallas Comments Received Can we split the question in multiple PICOs? (Methodologist) Forget about dispatch-assisted CPR…we should lobby for laws to make hands-only CPR training mandatory for the public with drivers licenses and Government ID cards (CPR instructor)

Dallas Proposed Treatment Recommendations We recommend that dispatchers should provide CPR instructions to callers in order to improve survival from OHCA. (serious indirectness, strong recommendation, low quality of evidence). We recommend that dispatchers should provide CPR instructions to callers in order to improve bystander CPR rates. (some indirectness, strong recommendation, low to very low quality of evidence).