Background
Canadian cardiac arrest victims collapse in their own home 85% of the time and half are witnessed by a family member or bystander. However, less than 20% receive bystander cardiopulmonary resuscitation (CPR), and the overall rate of survival to hospital discharge rarely exceeds 5%.

Early CPR has been clearly shown to be a factor associated with increased survival. Despite various community interventions in the past, bystander CPR rates remain low in Canada and rarely exceed 15% of all cardiac arrest cases in Ontario. In Ontario, 9-1-1 call takers began offering CPR instructions to callers reporting suspected cardiac arrests on April 1, 2004. The success of this intervention in increasing bystander CPR rates and ultimately survival to hospital discharge is directly linked to the ability of the call taker to accurately identify cardiac arrest over the telephone.

Agonal breathing is often present in cardiac arrest victims, and is defined as ineffective, gasping respirations occurring early on in cardiac arrest. This breathing can wrongfully be interpreted as a sign of life by 9-1-1 call takers thus can be a key factor explaining why cardiac arrest is not identified. If this behaviour can be changed, there is the potential to increase the proportion of victims receiving early bystander CPR, and ultimately improve survival for out-of-hospital cardiac arrest.

Using the Theory of Planned Behaviour (TPB) to identify factors affecting behaviour will aid in the design of appropriate forms of intervention associated with the successful identification of cardiac arrest and agonal breathing over the phone.

Objectives
Specific objectives are to 1) conduct iterative semi-structured interviews to identify behavioural factors influencing identification of agonal breathing and cardiac arrest by 9-1-1 call takers; 2) develop a survey based on a systematic review of the literature, the results of the semi-structured interviews, and theoretical constructs from the Theory of Planned Behaviour; 3) do a survey among provincial 9-1-1 call takers, and identify factors and strategies that might be targeted by Knowledge Translation interventions.

Methods
Phase 1: Interview Phase In the first phase of the project, we will conduct semi-structured interviews with 24 provincial 9-1-1 call takers. This will help identify and describe barriers and facilitators perceived to influence the ability of 9-1-1 call takers to recognise cardiac arrest and agonal breathing (behaviour). The data from this preliminary work will be used to inform the content of the larger survey.

Phase 2: Survey Development Phase Based on standard methodologies, content analysis of the qualitative data from Phase 1 will identify: 1) the most frequently perceived advantages and disadvantages of recognizing cardiac arrest (behavioural beliefs); 2) the most important people or groups of people (colleagues, supervisors, public) who would be affected by the ability of a 9-1-1 dispatcher to recognize cardiac arrest (normative beliefs); and 3) a list of the perceived barriers or facilitators that could hamper or facilitate recognition of cardiac arrest over the phone (control beliefs). The survey will be piloted with approximately 10 call-takers from the Ottawa CACC.

Phase 3: Survey Phase The survey will be distributed to our target population of approximately 800 9-1-1 call takers in the province of Ontario. An initial electronic notification about the survey will be sent to all identified call takers, followed later by the actual survey. Follow-up reminders will be sent over a 3 week period to encourage survey completion. We are anticipating a response rate of at least 60%.

Importance
We anticipate that this survey will identify key areas where improvements can be made in the training of 9-1-1 call takers or in the protocols they currently use for identification of cardiac arrest. At the moment, it is estimated that as many as 360 more lives in Canada could be saved annually by 9-1-1 assisted CPR instructions. The findings of this pilot project will be applied in a future project to test new interventions.

OHRI members:

Dr. Christian Vaillancourt
Dr. Jamie Brehaut
Dr. Jeremy Grimshaw
Dr. Ian Stiell
Dr. George Wells
Manya Charette
Ann Kasaboski

Other members:

Dr. Martin Osmond, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario