Telecommunicator Cardiopulmonary Resuscitation—A Strategy Whose Time Has Come for the Other Pandemic | Emergency Medicine | JAMA Network Open | JAMA Network
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Invited Commentary
Emergency Medicine
June 2, 2021

Telecommunicator Cardiopulmonary Resuscitation—A Strategy Whose Time Has Come for the Other Pandemic

Author Affiliations
  • 1Paris University, Paris Research Cardiovascular Center, INSERM, Paris, France
  • 2Emergency Department, Georges Pompidou European Hospital, Paris, France
  • 3Department of Emergency Medicine, University of Washington, Seattle
  • 4Department of Medicine, University of Washington, Seattle
  • 5Division of Emergency Medical Services, Public Health–Seattle & King County, Seattle, Washington
JAMA Netw Open. 2021;4(6):e217187. doi:10.1001/jamanetworkopen.2021.7187

Sanko et al1 investigated a health condition that could claim hundreds of thousands, even millions, of lives in the US and the rest of the globe. Older persons and persons with chronic illness are at greatest risk, although the condition occurs in younger, healthier persons. The condition disproportionately affects racial/ethnic minority and socioeconomically disadvantaged groups. These characteristics seem to describe the COVID-19 pandemic. However, the investigation by Sanko and colleagues1 involved sudden cardiac arrest.

Of course, there are considerable differences between the COVID-19 pandemic and sudden cardiac arrest, but some of the parallel features are notable: both conditions exact a large public health toll often on medically vulnerable persons, layperson behaviors and actions play a role in the disease process, and socioeconomically disadvantaged persons are disproportionately affected.2 As vaccination against COVID-19 continues, the pandemic that is sudden cardiac arrest persists and is often recognized but not made a priority for health policy and resource support.

Yet we should appreciate that real progress in cardiac arrest resuscitation is being made. Some of this progress involves understanding that the scientific principles described by the links in the chain of survival require programmatic translation to achieve successful implementation at the community level. As we advance a public health strategy for community-based resuscitation care, the approaches that adapt the initial links between early recognition, early activation of emergency response, early cardiopulmonary resuscitation (CPR), and early defibrillation offer the most accessible, cost-effective, and hence impactful opportunities to improve care and outcome.3

As we consider these links, we have to understand that the recognition of cardiac arrest by laypersons is challenging, often because of the agonal gasps by the patient experiencing the cardiac arrest. Moreover, many bystanders are not trained and/or are reticent to perform CPR. As a consequence, the 9-1-1 call to the telecommunicator is often the earliest and best opportunity for arrest recognition, early CPR, and potentially even public access defibrillation.

There is substantial evidence that the strategy of telecommunicator CPR can improve early recognition and early CPR, which translates to greater survival.4 The strategy has the telecommunicator use specific questions about consciousness and abnormal breathing to identify the patient and then coach the caller to position the patient and provide CPR. This approach relies on rapid and efficient communication, a reality that can be challenging especially when the caller has limited English proficiency. Previous investigation has demonstrated that limited English proficiency inhibits cardiac arrest recognition and bystander CPR and, in turn, may be associated with worse survival outcome, highlighting a mechanism that is associated with outcome disparity after cardiac arrest.5

Sanko et al1 compared optimized local telecommunicator algorithms to a commercial platform that is used across a wide range of emergency medical services (EMS) systems. They observed that the locally customized approach was associated with a greater proportion of patients receiving bystander CPR sooner regardless of English proficiency status. Close examination of the results also revealed that, even with the improvement associated with the local algorithm, the group with limited English proficiency still appeared to lag behind the group with English proficiency with regard to timely CPR delivery.

The authors described the limitations of the investigation.1 The cohort study was a secondary analysis of a before-and-after study, and thus a Hawthorne effect could potentially account for the improvements observed. The study also examined a single EMS system with a distinct telecommunicator expertise and callers with limited English proficiency profile that could affect generalizability. The number of callers with limited English proficiency was modest. The small sample size prevented a robust evaluation across subgroups that were defined, for example, by age, sex, or primary language that may confound or modify the observed relationships. These limitations notwithstanding, the study is important and highlights instructive topics for discussion that suggest potential next-step opportunities.

In the study, the Los Angeles Fire Department (LAFD) EMS system invested substantial effort to refine and adapt its dispatching algorithms.1 The effort has streamlined questions and incorporated rapid dispatch, which have forged a path toward providing lifesaving treatment sooner. The study highlighted the telecommunicators’ background and expertise as part of their success.1 However, the medical and operational leaders of the LAFD EMS system also deserve accolades for paying attention to the process details that translate into telecommunicator and bystander actions. The challenge and opportunity for the broad-based commercial platform then are to ascertain whether and how they might be able to generalize the local approach to a more heterogeneous set of stakeholders. Expanding the local improvement to the commercial platform can be a powerful public health opportunity.

The results of this study provide an opportunity to reflect on the future horizon and consider innovative solutions to the real and consequential challenge of emergency callers with limited English proficiency. We live in a world in which artificial intelligence can support human decisions and actions. The role of artificial intelligence in emergency communication and specifically in circumstances of limited English proficiency is just developing but could accelerate language recognition and translation that could aid in cardiac arrest recognition and CPR coaching.6

Sanko et al1 found that, approximately 10% of all emergency calls were classified as limited English proficiency calls in a community in which 19% of the population was considered to have limited English proficiency. This finding suggests the possibility that populations with limited English proficiency are less likely to activate 9-1-1 for incidence of cardiac arrest. If true, this finding would compound the health disparity observed among those with limited English proficiency. This topic is important in that it transcends the role of EMS personnel and engages a broad spectrum of societal stakeholders. We must listen, learn, and ultimately deliver public safety resources to groups who have not been well served by conventional approaches.

There is a specific challenge and opportunity for the LAFD EMS and the EMS systems of the surrounding LA County. The LAFD EMS has made progress toward the hallmark condition of cardiac arrest. The system has expert, dedicated medical and operational leadership, a highly capable telecommunicator and EMS workforce, and top-rated receiving hospitals. However, successful resuscitation involves forging such interdependent links that lifesaving progress can be undone in the absence of a coordinated effort. More than 15 years ago, a study of cardiac arrest resuscitation in Los Angeles was published that made an association between prehospital intervention, hospital care, and outcomes and highlighted the challenges (at that time) of providing a response for cardiac arrest in a large urban area.7 This measurement of the EMS system is foundational to understanding whether and how each link in the system contributes to clinical outcomes.3

More recently, other EMS systems in large cities that are challenged by a similar history of poor outcomes have established comprehensive measurement that has served to improve outcomes and to save more lives.8,9 Such an undertaking is substantial, but so are the talents and experiences of the collective involved, such as the LAFD EMS system. Moreover, the Cardiac Arrest Registry to Enhance Survival provides a tested electronic platform to support such an initiative. The work to measure the system can engage laypersons, prehospital professionals, and hospitals as a collective with a unifying goal and can provide public health dividends.

The study by Sanko et al1 demonstrates the potential of using telecommunicator CPR to improve early CPR in sudden cardiac arrest among 9-1-1 callers or bystanders with limited English proficiency and those with English proficiency. Like most relevant research, the study suggests important next steps for consideration by stakeholders committed to improving public health.

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Article Information

Published: June 2, 2021. doi:10.1001/jamanetworkopen.2021.7187

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Chocron R et al. JAMA Network Open.

Corresponding Author: Thomas Rea, MD, MPH, Department of Medicine, University of Washington, 401 Fifth Ave, Suite 1200, Seattle, WA 98104 (

Conflict of Interest Disclosures: None reported.

Sanko  S, Feng  S, Lane  C, Eckstein  M.  Comparison of performance of telecommunicator-assisted cardiopulmonary resuscitation among 9-1-1 callers with limited English proficiency.   JAMA Netw Open. 2021;4(6):e216827. doi:10.1001/jamanetworkopen.2021.6827Google Scholar
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Institute of Medicine.  Strategies to Improve Cardiac Arrest Survival: A Time to Act. National Academies Press; 2015.
Kurz  MC, Bobrow  BJ, Buckingham  J,  et al; American Heart Association Advocacy Coordinating Committee.  Telecommunicator cardiopulmonary resuscitation: a policy statement from the American Heart Association.   Circulation. 2020;141(12):e686-e700. doi:10.1161/CIR.0000000000000744PubMedGoogle ScholarCrossref
Bradley  SM, Fahrenbruch  CE, Meischke  H, Allen  J, Bloomingdale  M, Rea  TD.  Bystander CPR in out-of-hospital cardiac arrest: the role of limited English proficiency.   Resuscitation. 2011;82(6):680-684. doi:10.1016/j.resuscitation.2011.02.006 PubMedGoogle ScholarCrossref
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Del Rios  M, Weber  J, Pugach  O,  et al.  Large urban center improves out-of-hospital cardiac arrest survival.   Resuscitation. 2019;139:234-240. doi:10.1016/j.resuscitation.2019.04.019 PubMedGoogle ScholarCrossref
May  S, Zhang  L, Foley  D,  et al.  Improvement in non-traumatic, out-of-hospital cardiac arrest survival in Detroit from 2014 to 2016.   J Am Heart Assoc. 2018;7(16):e009831. doi:10.1161/JAHA.118.009831 PubMedGoogle Scholar
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