1. Report on Suspected Cardiac Arrest Audio Recordings February 2, 2012

2. Contents 1. Introduction 2. Breakdown of Total Calls 3. Statistical Overview: Total Calls 4. Table 1: Measurements Before and After Staff Training and Protocol Revisions 5. Calls Where CPR Instructions Were Not Started 6. Calls Where CPR Instructions Did Not Result in CPR 7. Timelines 8. Potential Survivors 9. Summary

3. Sudden cardiac arrest (SCA) is a major public health problem in North America, claiming the lives of an estimated 250,000 to 300,000 people every year. The chance a victim survives is very low. Estimates suggest that fewer than eight percent live to hospital discharge in the United States. There are roughly 15 instances of SCA in Arizona every day. Emergency call-takers and dispatchers play a profound role in the Chain of Survival, an orchestrated series of rescue actions proceeding from bystander CPR to early defibrillation, swift transport to a cardiac center, and standardized care until the patient is discharged. Bystander CPR represents a great but frequently-missed opportunity: it can double or triple the chance a patient survives, but in general is performed in about a third of all cases. Because survival likelihood falls by 7-10 percent per minute, time is of the essence. The Save Hearts in Arizona Registry and Education program (SHARE), a statewide venture embracing municipal fire departments, ambulance agencies, hospitals, the Arizona Department of Health Services, and the University of Arizona Sarver Heart Center, invites dispatch centers and Public Safety Answering Points to partner in a precious challenge: improving telephone-assisted CPR in an effort to save lives from SCA in Arizona. This HIPAA-exempt program strives to help partners implement the recommendations outlined in the recently-published American Heart Association Scientific Advisory Statement on telephone-assisted CPR. The program advocates a continuous quality-improvement initiative that measures and enhances the delivery of telephone–provided CPR instructions, and provides partners with standardized, confidential reports detailing process and outcome. The following report is based on 103 audio recordings provided to SHARE. The calls were received at the dispatch center on or after November 7, 2011, when the dispatch center “went live” after training its staff members in a revised protocol for handling suspected cardiac arrest calls. SHARE listened to and translated these calls into data sets reflecting important standard-of-care variables. The outcomes for these measures improved dramatically from their baseline values, which were generated from calls processed before the training and protocol revisions were executed. These improvements are readily apparent in Table 1 on page 4. SHARE sincerely thanks the dispatch center for its valued partnership. Our joint efforts to improve the delivery of telephone pre-arrival instructions for cardiac arrest is already paying dividends. Since November 7, SHARE has identified the EMS and hospital records of ten patients who may owe their lives to the bystander CPR they received through the conscientious efforts of call-takers and dispatchers. SHARE firmly believes that, together, we can save many more lives in the communities we serve. Micah Panczyk 9-1-1 CPR Program Manager Arizona Department of Health Services 602-364-2846 http://9-1-1CPRDispatch.azshare.gov Introduction 1

4. Total calls n=103 CPR in progress n=6 Need for CPR not indicated n=26 Remainder n=71 SHARE and CT/dispatchers recognized need for CPR n=69 SHARE recognized need for CPR but CT/dispatchers did not n=2 CPR instructions were started n=41 Need recognized but instructions not given n=28 Compressions only delivered n=33 No CPR delivered n=8 2 Breakdown of Total Calls

5. 1. % of total calls excluded from analysis: 31.0 (32/103) - % of total calls excluded because need for CPR was not indicated (includes cases of obvious death): 25.2 (26/103) - % of total calls excluded because CPR was already in progress when call was received: 5.8 (6/103) 2. % of qualifying calls where call-takers and dispatchers recognized the need for CPR: 97.2 (69/71) 3. % of qualifying calls where caller refused or was unable to perform CPR: 7.2 (5/69) 4. % of qualifying calls where telephone instructions to rescuer resulted in both compressions and ventilations: 0.0 (0/41) 5. % of qualifying calls where telephone instructions to rescuer resulted in compressions only: 80.4 (33/41) 6. % of qualifying calls where victims received some form of telephone-assisted bystander CPR: 46.4 (33/71) 7. Average time elapsed from start of call for SHARE evaluator to recognize the need for CPR: 61 seconds 8. Average time elapsed from start of call for call-takers and dispatchers to recognize the need for CPR: 86.8 seconds 9. Average time elapsed from start of call to start of CPR instructions: 130 seconds 10. Average time elapsed from start of call to first compression: 182 seconds Statistical Overview: Total Calls = 103 3

6. MEASUREMENTBEFORE REVISIONSPOST-REVISIONSCHANGE 1. % CT/dispatch recognition of need for CPR82.297.2+15 2. % refusal or inability to do CPR31.57.2-24.3 3. Ave. time to recognition89.3 sec86.8 sec-2.5 sec (3%) 4. Dispatch/SHARE recognition time1.611.43-.18 (11%) 5. % instructions started31.457.7+26.3 6. Ave. time to start instructions175.1 sec130.0 sec-45.1 sec (26%) 7. Ave. time to first compression240.4182.0-58.4 sec (24%) 8. % of telephone-assisted bystander CPR17.9*46.4+ 28.5 Table 1: Measurements Before and After Staff Training and Protocol Revisions Definitions 1.The fraction of qualifying calls where call-takers and dispatchers recognized the need for CPR. 2.The fraction of qualifying calls where the caller refused or was unable to perform CPR. 3.The average time elapsed from call receipt to the moment when call-takers and dispatchers recognized the need for CPR. 4.The value from #3 divided by the average time to recognition by SHARE evaluators. 5.The fraction of qualifying calls where CPR instructions were started. 6.The average time elapsed from call receipt to the moment when CPR instructions began. 7.The average time elapsed from call receipt to the moment when the rescuer delivered the first compression. 8.The fraction of qualifying calls where telephone CPR instructions resulted in bystander CPR. * This figure is 30% if cases where only ventilations were given are included. 4

7. Calls Where CPR Instructions Were Not Started In 69 cases where call-takers and dispatchers recognized the need for CPR, CPR instructions were not started in 28. Below are reasons why in each case: 1.Caller was not the rescuer; call-taker/dispatcher could have asked to speak with rescuer. 2.Caller refused instructions. 3.Change in victim’s breathing status before instructions started. 4.Caller refused instructions. 5.Caller refused instructions. 6.Change in victim’s consciousness status before instructions started. 7.Change in victim’s consciousness status before instructions started. 8.Caller refused instructions; call-taker/dispatcher not assertive enough: “Do you want to try CPR?” 9.Victim vomited and was reported breathing after initial assessment. 10.Change in victim’s consciousness status before instructions started. 11.Change in victim’s breathing status before instructions started. 12.Change in victim’s consciousness and/or breathing status before instructions started. 13.Rescuer unable to get victim onto floor; call-taker/dispatcher not assertive enough. 14.Change in victim’s consciousness status before instructions started. 15.Rescuer couldn’t get husband out of chair. 16.Caller and caller’s brother couldn’t get victim onto floor; call-taker/dispatcher not assertive enough. 17.Caller refused instructions; wife possibly in diabetic coma. 18.Change in victim’s consciousness status before instructions started; possible seizure 19.Rescuer unable to get victim onto floor. 20.Caller would not check on victim; call-taker/dispatcher not assertive enough. 21.Rescuer unable to move victim. 22.Rescuer unable to get victim onto floor. 23.Caller left phone; help arrived before instructions started. 24. Change in victim’s consciousness status. 25. Caller not with patient. 26. Call-taker/dispatcher could be more assertive. 27. Rescuer unable to get victim to the floor. 28. Professional rescuers arrived before instructions started. Breakdown: - Number of times victim’s status changed: 10 - Number of times caller refused instructions: 5 - Number of times rescuer(s) couldn’t move victim: 7 - Number of times other: 6 5

8. Calls Where CPR Instructions Did Not Result in CPR In 41 cases where CPR instructions were started, 8 did not result in the delivery of compressions. Below are reasons why in each case: 1. Victim regained consciousness before compressions were started. 2. Fire department arrived at 3 minutes and 40 seconds, before compressions were started. 3. Change in victim’s consciousness status before compressions started. 4. Change in victim’s breathing and consciousness status before compressions started. 5. Language barrier – Spanish; caller left the phone. 6. Victim became responsive at 2 minutes and 42 seconds into the call. 7. Possible seizure mistaken for cardiac arrest. 8. Police arrived just before compressions started. Breakdown: - Number of times victim’s status changed: 4 - Number of times fire or police personnel arrived before CPR started: 2 - Number of times other: 2 6

9. First Interval (Recognition of need for CPR): 89 Second Interval (Start of instructions): 86 175 0 Third Interval (Start of compressions): 65 240 89 First Interval (Recognition): 87 Second Interval (Instructions): 43 Third Interval (Compressions): 52 0 87130 182 Timelines The graphics below represent three intervals inherent in providing telephone-assisted bystander CPR. The top shows baseline numbers (in seconds). The bottom reveals numbers generated from calls evaluated after training and protocol revisions. They suggest that the First Interval is a key in efforts to further reduce time to first compression. 7

10. GENDERAGECAUSETIME FIRST COMPRESSION 1. Male57Full cardiac arrest3 min 2. Female24Respiratory arrest2:35 3. Male21Respiratory arrest3:48 4. Female21Full cardiac arrest2:50 5. Female45Overdose – respiratory arrest3:06 6. Male44Overdose – full arrest2:36 7. Female4 daysRespiratory arrest2:23 8. Male47Full cardiac arrest4:32 9. unknownunknownRespiratory arrest4:15 10. unknownunknownRespiratory arrest4:10 Potential Survivors 8 Since November 7, 2011, SHARE has identified the EMS and hospital records of ten patients who may owe their lives to the bystander CPR they received through the conscientious efforts of call-takers and dispatchers.

11. Call-takers and dispatchers have made significant improvements in the delivery of telephone-assisted CPR since completing their training and executing protocol revisions. Advances in two categories in Table 1 (page 4) capture this success clearly: the rate of telephone-assisted bystander CPR and the average time to first compression. The first increased by almost 30 percent over the baseline numbers, while the second fell by 58 seconds. These improvements hold great promise. Time to first compression is a key element in resuscitation attempts (the chance a victim survives falls by 7 to 10 percent per minute after onset of cardiac arrest), and bystander CPR can increase survivorship 2 to 3 times. To date, SHARE has identified the EMS and hospital records of ten patients who may owe their lives to the telephone-assisted bystander CPR they received through the efforts of call-takers and dispatchers. The Timelines (page 7) suggest a focus for future coaching: reducing the time to recognition in order to reduce the time to first compression. Recognizing the need for CPR is a call-taker or dispatcher’s first challenge. Frantic callers can be hard to manage for even the most assertive call-taker or dispatcher, and the number of callers who report “changes” in a victim’s status (pages 5 and 6) demonstrates that solid answers to diagnostic questions can be elusive. Continuous quality-assurance evaluation is essential to sustain progress. By measuring and placing the components of telephone- assisted CPR in context, we can identify successes and subtleties of process that point the way to continued improvements. SHARE thanks the dispatch center for its valued partnership, and for its efforts to build the exemplary telephone-assisted CPR service in Arizona. Summary 9