Bystander CPR: A key link in the chain of survival

With 359,000 people suffering out-of-hospital cardiac arrests in 2013, death by cardiac disease continues to be the number one killer in the United States [1]. Significant research in cardiac resuscitation has been ongoing since the 1950s, with time, effort and money examining the multiple variables affecting survival rates.

One component of the cardiac chain of survival, bystander CPR, appears to play a major role in the increase of survival to discharge rates in cardiac arrest. It is critical that EMS agencies play their part in strengthening this part of the resuscitation strategy in order to improve community health.

In 1988 the phrase "chain of survival" was coined to describe a series of events that if strung together and performed in a timely manner, would greatly improve the chances of survival from sudden cardiac arrest in the out of hospital setting [2]. These events include:

• Early access to the emergency cardiac care system by recognizing sudden cardiact arrest quickly and calling 911
• Early CPR by those nearest to the sudden cardiac arrest, bystanders
• Early defibrillation of ventricular arrhythmias
• Early advanced level care by trained professionals

Throughout the 1990s focus was placed on the back end of the chain of survival, i.e. the medications and procedures being done by paramedics and emergency department staff to improve survival rates. However, by the 2000s attention turned toward the improvement of the front end of the chain, specifically how to improve the incidence of bystander-provided CPR at the moment of collapse.

It was already known by the mid-1980s that early CPR by members of the public, performed before the arrival of trained responders, improved sudden cardiac arrest survival rates [3]. Yet the numbers of bystanders trained in CPR remains low and range considerably from one community to the next. Rates of 15 to 30 percent of sudden cardiac arrest receiving bystander CPR have been reported [4, 5]. Southern states, especially in areas with higher proportions of Hispanic and African American populations and lower median incomes have lower rates of CPR training [6].

Why are bystander CPR rates so low"
There have been a number of theories as to why bystander CPR rates have remained historically low, including fear of cross infection, fear of liability, the complexity of traditional CPR instruction that included mouth-to-mouth breathing techniques, and ultimately a lack of confidence in performing correctly in real life situations [7].

Regardless of the cause, it is essential to increase the percentage of sudden cardiac arrest patients who receive prearrival CPR, as a cost effective and efficacious method to improve survival to discharge rates.

Expanding CPR training opportunities
Up until the late 2000s, CPR courses taught to bystanders took several hours to complete, were costly and resource intensive, creating a barrier to readily accessible training opportunities. With the 2010 American Heart Association guideline recommendation that compressions-only CPR training may be more effective in training bystanders, organizations around the nation made an effort to train large numbers of bystanders in this technique. Without the extra burden of having to teach manual ventilation techniques and focusing on high-quality chest compressions practice, the time frame for training shortened considerably. Research has supported that change; studies comparing compressions only CPR versus "standard CPR" by nonprofessional bystanders showed a higher survival rate for sudden cardiac arrest patients who received compression only CPR [8,9].

Self-instructional kits have been created by the AHA and other training organizations that allows video-driven instruction to occur any time, and in any space [10]. School district CPR programs have used these kits to train middle and high school students during class, with the intent of having the students bring the kits home and train family members. This has resulted in a large number of citizens being trained in CPR at a modest cost [11, 12].

Internet-based CPR training has also drawn attention. A small study indicated that students who viewed an animation of CPR being done on a manikin performed ventilations and chest compressions just as well as students who received one hour of instructor-led training [13].

Widespread adoption of dispatch-assisted CPR training
Despite increasing access to CPR training, it is still likely that at the temporal moment of sudden cardiac arrest, the person closest to the victim is capable of performing hands-only CPR. 911 telecommunicators can provide just in time, over-the-phone guidance for individuals who are willing to provide CPR. Multiple studies have shown the efficacy of dispatch CPR instructions in improving sudden cardiac arrest survival rates [14, 15].

Providing reassurance to the would-be lay rescuer
The AHA has recommended that bystanders be educated on the virtually nonexistent risk of disease transmission during CPR. Information about relevant Good Samaritan laws should be provided, and worksites and public spaces should have basic personal protective equipment such as gloves and pocket masks co-located with public access automated external defibrillators [16].

The role of EMS agencies
As the first professionally trained link in the chain of survival, EMS agencies can play a critical role in training its community members in CPR and AED use. Examples include:

• Sponsoring large-scale, one-day events such as Save-A-Life Saturday
• Training middle school health teachers how to teach compression-only CPR to their students and providing training equipment when needed [17]
• Implementing dispatch-assisted CPR protocols within the 911 call center
• Advocating for legislative changes that encourage or mandate CPR training in public schools
• Work with government officials and other stakeholders to place AEDs in public areas and locations where the likelihood of SCA is higher
• Publically recognize bystanders who make the effort to perform CPR at the temporal moment of SCA

SCA is a public health disease that responds to carefully planned interventions based on evidence. Given the growing body of evidence that shows the benefit of bystander CPR, EMS agencies can take the lead to improve their community's ability to respond when seconds truly count.

References

1. American Heart Association. Cardiac Arrest Statistics. http://ift.tt/1RWfAJJ retrieved 20 April 2016.

2. Newman M (1989). "The chain of survival concept takes hold". JEMS 14: 11–13.

3. Ritter G et al. The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J. 1985 Nov;110(5):932-7.

4. De Maio VJ et al. Ontario Prehospital Advanced Life Support (OPALS) Study Group. CPR-only survivors of out-of-hospital cardiac arrest: implications for out-of-hospital care and cardiac arrest research methodology. Ann Emerg Med. 2001; 37: 602–608.

5. Lateef F, Anantharaman V. Bystander cardiopulmonary resuscitation in prehospital cardiac arrest patients in Singapore. Prehosp Emerg Care. 2001; 5: 387–390.

6. Anderson ML et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014 Feb 1;174(2):194-201.

7. Swor R et al. CPR training and CPR performance: do CPR-trained bystanders perform CPR" Acad Emerg Med. 2006; 13: 596–601.

8. Hüpfl M, Selig FS, Nafele P. Chest Compression-Only CPR: A Meta-Analysis. Lancet. 2010 Nov 6; 376(9752): 1552–1557.

9. Dias JA et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation. 2007; 72: 108–114.

10. American Heart Association. CPRanytime.org website. www.cpranytime.org.

11. Isbye DL, Meyhoff CS, Lippert FK, Rasmussen LS. Skill retention in adults and in children 3 months after basic life support training using a simple personal resuscitation manikin. Resuscitation. 2007;74:296–302

12. Lorem T, Palm A, Wik L. Impact of a self-instruction CPR kit on 7th graders' and adults' skills and CPR performance. Resuscitation. 2008;79:103–108

13. Choa M-H, Park I-C, Chung HS, Yoon YS, Kim S-H, Yoo SK. Internet-based animation for instruction in cardiopulmonary resuscitation. J Telemed Telecare. 2006; 12 (suppl 3): 31–33.

14. Hallstrom AP, Cobb LA, Johnson E, Copass MK. Dispatcher assisted CPR: implementation and potential benefit: a 12-year study. Resuscitation. 2003;57: 123–129.

15. Dias JA et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation. 2007; 72: 108–114.

16. Abella BS et al. AHA Scientific Statement: Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation. Circulation. 2008; 117: 704-709.

17. Daubs B. Local students and Save Lives Sonoma take CPR lessons to heart. The Healdsburg Tribune, 19 February 2014. http://ift.tt/1WuVI2Q retrieved 5/5/16.

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