What factors delay initiation of bystander CPR in out-of-hospital cardiac arrest? Results from an analysis of 200 recorded ambulance calls.

Abstract

Background: Cardiopulmonary resuscitation (CPR) is often not initiated promptly enough in out-of-hospital cardiac arrest, even when call-handlers provide instructions. Identifying the critical, potentially modifiable, barriers to CPR is essential. Our aim was to identify factors associated with delays (1) positioning patient flat and (2) initiating CPR in recordings of cardiac arrest calls and to explore potentially modifiable behavioural factors. Methods: Retrospective analysis of 200 call recordings to the Scottish Ambulance Service January 2019–December 2020 during which dispatcher-assisted CPR instructions were provided. Potential barriers were coded inductively. Log rank tests were used to explore differences in ‘time to position patient flat’ and ‘time to initiate CPR’ depending on the presence/absence of potential barriers identified. Results: A random sample of 200 calls were selected from 11 275 potentially eligible calls. Patients in those calls were mostly male (61%), most aged 40–80s; callers were mostly female spouses. Time to position patient flat: median 40 s (IQR: 15.5–82.0), time to initiate CPR: median 50 s (IQR: 36–92). Between 1 and 11 potential barriers were identified in calls (median=4, IQR:2–6). The most common barriers identified were communication (48%), emotion (45.5%) and physical challenges (38.5%). Various physical challenges, concern patient too heavy, concern that it was too late/futile, concern about physical ability, concern about doing harm and caller being ‘upset’ were significantly associated with delays to positioning the patient flat. Callers ‘not knowing how’ to do CPR; expressing concerns about doing harm, expressing anger and various physical challenges including concerns about ability were associated with delays in initiating CPR. Many significant barriers are potentially amenable to behavioural techniques. Conclusion: Barriers to ‘positioning the patient flat’ and ‘initiating CPR’ are not the same. Concerns vary, and so identifying and addressing the specific concerns for individual callers at each stage might facilitate earlier CPR. Many of the issues delaying CPR are potentially modifiable with behavioural techniques.