Texting for CPR Feasible in Out-of-Hospital Cardiac Arrest —City's EMS system to alert nearby trained laypersons raised rates of early CP

by Crystal Phend, Senior Staff Writer, MedPage Today

Reprinted with permission by Michelle Nostheide, American Heart Association

Pulling in nearby CPR-trained lay people via mobile-phone dispatch while paramedics are on their way to an out-of-hospital cardiac arrest appears feasible, a Swedish study showed.

The rate of bystander CPR jumped to 62% with use of a mobile-phone positioning system in Stockholm that could instantly locate and dispatch one of about 6,000 mobile-phone users within 500 m (less than a third of a mile) who were trained in CPR and volunteered to be available.

By comparison, that rate was 48% (P<0.001) in a control group randomized to no lay-volunteer dispatch in the blinded trial, Leif Svensson, MD, PhD, of the Karolinska Institutet in Stockholm, and colleagues reported in the New England Journal of Medicine.

Secondary outcomes -- return of spontaneous circulation, initial cardiac rhythm, and 30-day survival -- didn't differ between those groups.

However, the 14 percentage point increase was "not powerful enough to affect the survival rate in our limited study population," the researchers noted.

A much larger patient population would be required to prove that level of benefit, although there's plenty of other evidence to show that bystander-initiated CPR improves survival rates, they pointed out.

In a second study from the group, using a national cardiac arrest registry there, the odds of survival to 30 days were 2.15-fold better with any CPR before paramedic arrival after weighting for location and cause of cardiac arrest, emergency response time, and other key factors (unadjusted rate 10.5% versus 4.0%, P<0.001).

"Increasing the rate of bystander CPR is a major public health concern, but to date efforts in this domain have been laudable but simple -- offer more training," commented F. Perry Wilson, MD, of Yale and a MedPage Today medical reviewer. "Even the best training courses can only reach a fraction of the community."

Typical bystander CPR rates in the U.S. don't even reach that of the dispatch trial's control group, so there's every reason to roll out this same kind of program here, he said, calling the concept "awesome."

"I think systems like this will save lives and should be broadly rolled out to as many municipalities as possible," Wilson said in a video commentary for MedPage Today. "After all, our cell phones are tracking our every movement anyway. Better to use them for something like this than just targeted advertisements and government surveillance."

However, an accompanying editorial in the NEJM was more skeptical about U.S. applicability.

For one thing, "the U.S. EMS system is more fragmented than the Swedish system," wrote Comilla Sasson, MD, PhD, of the American Heart Association in Dallas, and David J. Magid, MD, MPH, of the University of Colorado and Colorado Cardiovascular Outcomes Research Consortium in Denver.

"Most 911 dispatch centers in the United States cannot automatically identify call locations from cell phones and cannot send or receive text messages," they added.

"Second, no single database exists to register phone numbers of trained volunteers," the editorialists pointed out. "If even a small proportion of the tens of millions of people who learn CPR each year opted into inclusion in a database, the pool of potential responders could be tremendous.

"Third, lay volunteers may be reluctant to allow dispatchers to have constant access to their location or fear being sued if they do not respond to a call."

While there are always questions of Good Samaritan laws, safety, and such that might differ from Sweden, there is already a GoodSAM App for people to register to respond to cardiac arrest and other emergency alerts nearby, Anand Swaminathan, MD, MPH, director of the NYU/Bellevue Emergency Department in New York City, commented in an email to MedPage Today.

In Svensson's study, "almost 10,000 people voluntarily joined the program without any financial compensation, and no major adverse events were reported," they noted.

Bigger benefits probably would have been seen if every activation of the system had been successful, the group suggested. The system wasn't activated at night, for children, and for a variety of other reasons.

The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests from April 2012 through December 2013 in Stockholm: 46% in the intervention group and 54% in the control group.

While the ethics of not dispatching CPR-trained people when possible might be questioned, Wilson congratulated that choice in the trial design.

"These interventions which seem like they're all upside can often have unintended consequences and they do need to be rigorously studied," he said.

Despite the challenges, "we must empower people who are trained in CPR by integrating them into the EMS system and alerting them when a cardiac arrest occurs," the editorialists agreed. "If we can send these volunteers to the right place at the right time, we may finally improve rates of survival after out-of-hospital cardiac and realize the public health potential of bystander-initiated CPR."

The rate of bystander CPR jumped to 62% with use of a mobile-phone positioning system in Stockholm that could instantly locate and dispatch one of about 6,000 mobile-phone users within 500 m (less than a third of a mile) who were trained in CPR and volunteered to be available.

However, an accompanying editorial in the NEJM was more skeptical about U.S. applicability.

For one thing, "the U.S. EMS system is more fragmented than the Swedish system," wrote Comilla Sasson, MD, PhD, of the American Heart Association in Dallas, and David J. Magid, MD, MPH, of the University of Colorado and Colorado Cardiovascular Outcomes Research Consortium in Denver.

"Most 911 dispatch centers in the United States cannot automatically identify call locations from cell phones and cannot send or receive text messages," they added.

"Second, no single database exists to register phone numbers of trained volunteers," the editorialists pointed out. "If even a small proportion of the tens of millions of people who learn CPR each year opted into inclusion in a database, the pool of potential responders could be tremendous.

"Third, lay volunteers may be reluctant to allow dispatchers to have constant access to their location or fear being sued if they do not respond to a call."

While there are always questions of Good Samaritan laws, safety, and such that might differ from Sweden, there is already a GoodSAM App for people to register to respond to cardiac arrest and other emergency alerts nearby, Anand Swaminathan, MD, MPH, director of the NYU/Bellevue Emergency Department in New York City, commented in an email to MedPage Today.

In Svensson's study, "almost 10,000 people voluntarily joined the program without any financial compensation, and no major adverse events were reported," they noted.

Bigger benefits probably would have been seen if every activation of the system had been successful, the group suggested. The system wasn't activated at night, for children, and for a variety of other reasons.

The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests from April 2012 through December 2013 in Stockholm: 46% in the intervention group and 54% in the control group.

While the ethics of not dispatching CPR-trained people when possible might be questioned, Wilson congratulated that choice in the trial design.

"These interventions which seem like they're all upside can often have unintended consequences and they do need to be rigorously studied," he said.

Despite the challenges, "we must empower people who are trained in CPR by integrating them into the EMS system and alerting them when a cardiac arrest occurs," the editorialists agreed. "If we can send these volunteers to the right place at the right time, we may finally improve rates of survival after out-of-hospital cardiac and realize the public health potential of bystander-initiated CPR."

From the American Heart Association:

2015 Heart and Stroke Statistical Update

Svensson's study was supported by the Swedish Heart-Lung Foundation and Stockholm County.

Herlitz's study was supported by grants from the Laerdal Foundation for Acute Medicine in Norway, the Swedish Heart–Lung Foundation, and the Swedish Association of Local Authorities and Regions.

Both groups disclosed no relevant relationships with industry.

The editorialists disclosed no relevant relationships with industry.