International Emergency Nursing 23 (2015) 254–259

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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n

REVIEW

Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (CPR): A mixed-methods study of simulated telephone-assisted CPR Helena Nord-Ljungquist RN, CCN, MSc (Lecturer) a,*, Margareta Brännström RNT, PhD (Senior Lecturer) b, Katarina Bohm RN, PhD (Lecturer) c a

Department of Health Sciences, Luleå University of Technology, Lulea, Sweden Strategic Research Program in Health Care Sciences (SFO-V), ‘Bridging Research, Practice for Better Health’, Department of Nursing, Umeå University, Umeå, Sweden c Department of Clinical Science, Education, Karolinska Institutet, Södersjukhuset, Sweden b

A R T I C L E

I N F O

Article history: Received 18 August 2014 Received in revised form 15 December 2014 Accepted 21 December 2014 Keywords: Telephone-assisted cardiopulmonary resuscitation (T-CPR) Emergency medical dispatcher (EMD) Laypersons Communication Mixed method

A B S T R A C T

Background: In the event of a cardiac arrest, emergency medical dispatchers (EMDs) play a critical role by providing telephone-assisted cardiopulmonary resuscitation (T-CPR) to laypersons. The aim of our investigation was to describe compliance with the T-CPR protocol, the performance of the laypersons in a simulated T-CPR situation, and the communication between laypersons and EMDs during these actions. Methods: We conducted a retrospective observational study by analysing 20 recorded video and audio files. In a simulation, EMDs provided laypersons with instructions following T-CPR protocols. These were then analysed using a mixed method with convergent parallel design. Results: If the EMDs complied with the T-CPR protocol, the laypersons performed the correct procedures in 71% of the actions. The single most challenging instruction of the T-CPR protocol, for both EMDs and laypersons, was airway control. Mean values for compression depth and frequency did not reach established guideline goals for CPR. Conclusion: Proper application of T-CPR protocols by EMDs resulted in better performance by laypersons in CPR. The most problematic task for EMDs as well for laypersons was airway management. The study results did not establish that the quality of communication between EMDs and laypersons performing CPR in a cardiac arrest situation led to statistically different outcomes, as measured by the quality and effectiveness of the CPR delivered. © 2014 Elsevier Ltd. All rights reserved.

1. Introduction Cardiovascular disease is one of the leading causes of death in the Western world. In Europe it is estimated that 275,000 people each year suffer cardiac arrest outside hospitals, 29,000 of them surviving if life-saving treatment was started (Atwood et al., 2005). In Sweden during the years 1990–2012 a total of 66,476 persons were registered as having suffered an out-of-hospital cardiac arrest (OHCA), where life-saving treatment had been begun. The 1-month survival rate after a cardiac arrest has gradually increased, from 4.2% at the beginning of the century to 10.3% in 2012 (Swedish National Register of Cardiac Arrest Annual Report, 2013).

* Corresponding author. Department of Health Science, Luleå University of Technology, SE-971 87 Luleå, Sweden. Tel.: +46 920 49 38 46; fax: +46 920 49 38 50. E-mail address: [email protected] (H. Nord-Ljungquist). http://dx.doi.org/10.1016/j.ienj.2014.12.001 1755-599X/© 2014 Elsevier Ltd. All rights reserved.

Early alarm is one of the important factors contained in the concept of the ‘chain of survival’ (Nolan et al., 2006). The first link in this chain is the call to the Emergency Medical Communication Centre (EMCC). The EMCC in Sweden is assigned to ensure that people in need receive adequate help. They receive about 10,000 calls a day to the emergency number 112. These calls are about acute medical conditions, accidents, fires, burglaries, and the like (SOS Alarm, Sustainability and Annual Report, 2011). To assess and prioritize the need for care, a decision support tool, the ‘Swedish Medical Index’, is used. The index contains 30 chapters on various health problems and a protocol for OHCA with clear instructions. (Laerdal, Swedish Index to Emergency Medical Assistance, 2007). The importance of good communication in the interaction between patient and healthcare professionals has emerged in previous research (Henry et al., 2012; Pettinari and Jessopp, 2001; Travelbee, 1971). The second link in the chain of survival is to start cardiopulmonary resuscitation (CPR). An EMD can give telephone-assisted cardiopulmonary resuscitation (T-CPR) to the layperson until the

H. Nord-Ljungquist et al./International Emergency Nursing 23 (2015) 254–259

ambulance arrives. There is a greater chance of survival if CPR is started within 2 minutes after an OHCA has occurred (Holmberg et al, 2001). Chances of survival are two to three times greater for people who have suffered from OHCA if they receive early CPR (Herlitz et al., 2005; Holmberg et al., 2000; Rea et al., 2001). The European and Swedish CPR guidelines for 2010 are based on the Liaison Committee on Resuscitation (ILCOR), and T-CPR instructions are based on their recommendations. The initial instruction to the layperson is intended to create a free airway in the patient and subsequently to perform chest compressions only. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions/minute, to allow full chest recoil and to minimize interruptions in chest compressions (Nolan et al., 2010). Previous studies have evaluated the results of the given instructions, but no studies have been found that have the purpose of evaluating compliance with T-CPR protocols by EMD and laypersons, as well as the quality of performed CPR. Previous T-CPR simulation studies showed disappointing results for chest compression depth and frequency (Cheung et al., 2007; Deakin et al., 2007; Van Tulder et al., 2014). The aim of our investigation was to describe compliance with the T-CPR protocol, the performance of the laypersons in a simulated T-CPR situation, and the communication between laypersons and EMDs during these actions. 2. Methods 2.1. Selection This pilot is a retrospective observational study involving the analysis of recorded audio files and videos made in the spring of 2009. EMDs from four EMCCs in central Sweden participated in planned CPR training. All (n = 18) were invited to participate and agreed to be part of the study. The laypersons were acquaintances and relatives of administrative personnel at the EMCC. Twenty laypersons agreed to participate in the study. All EMD and laypersons participated voluntarily and gave informed consent. This study was approved by the Regional Ethics Committee in Stockholm (Ref. 2010/863-31/4). 2.2. Data collection For obvious reasons, bystander CPR per se can only be studied in simulations. In order to decrease the Hawthorn effect, the EMDs were in their normal working environment and were instructed to handle the phone call as a real-life situation as far as possible. A dedicated phone number to the EMCC was used to ensure that EMDs would be aware that the call was part of the study. All calls were recorded when the EMD gave T-CPR (‘Swedish Medical Index’ version 13, 2009 – 1: 2) to the laypersons. The Swedish Medical Index (the protocol) from 2009 includes instructions on both chest compression and mouth-to-mouth ventilation. In this investigation we wanted to follow the new recommendations from the 2010 European guidelines, which do not include mouth-to-mouth instruction (Nolan et al., 2010). Practical elements that belong to the management of an emergency call, such as positioning on the map, were removed. All 20 laypersons were filmed when they performed CPR on Laerdals CPR Rescue Annie and Laerdal PC Skillreporting was employed to assess the quality of the CPR. The registration of values from CPR Rescue Anne started when the layperson connected with the EMD. The laypersons were instructed to say, ‘My wife/husband just had a fall in the kitchen. What should I do?’ If the EMD asked how the person’s respiration was, the laypersons responded that he or he or she was not breathing. The recordings took place in a separate room at the EMCC. The EMDs’ compliance with the protocol was analysed by the first and last author, in consensus. The films were examined visually by the first author and a specialist in

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anaesthesia/CPR instructor. The films were examined separately for each layperson, to ensure he or she could perform the actions from the instructions given by EMD. The action was evaluated with a ‘yes’ or ‘no’ regarding whether a free airway was created and whether the layperson stood on his or her knees close to the person’s upper chest, used straight arms, and counted out loud. The two authors examining the films differed in their evaluations of some of the films. In such cases, a third-party specialist in anaesthesia/CPR instructor viewed the film and gave the deciding appraisal. 2.3. Method of analysis A convergent parallel mixed method was used in this pilot study (Creswell and Plano, 2011). The method involves the collection and analysis of qualitative and quantitative data done in parallel and equivalent. According to Creswell and Plano (2011), the results merged; they are discussed based on similarities and differences and/ or summarized in the discussion or in a table. One way to bring data together is to transform the qualitative results to quantitative variables – that is, to change categories into numbers. Statistical analysis was conducted on the transformed data and quantitative variables. 2.4. Qualitative analysis The 20 audio files of observed communication between EMDs and laypersons were analysed using a qualitative content analysis approach (Burnard, 1991, 1996; Graneheim and Lundman, 2004). The transcribed interviews were read several times to obtain a sense of the whole. The text was then divided into meaningful units, which were coded and sorted into groups with similar content and then abstracted into subcategories. Finally, the subcategories were abstracted into categories. 2.5. Quantitative analysis Background variables are descriptively described. Normally distributed variables (i.e., chest compression depth and frequency) are presented as mean and standard deviations (SD). CPR instructions were evaluated based on compliance with the T-CPR protocol by the EMD in the categories of correct, partially correct, incorrect, and ‘instruction not given’. These were then dichotomized: correct or incorrect. A significance analysis was performed between the dichotomous qualitative variables’ correct or incorrect application of the T-CPR protocol by the EMD and the performed actions of laypersons using Fisher’s exact test. The main categories – good communication and a lack of communication – were transformed into dichotomous variables and together with the qualitative variables that described performed actions were analysed using Fisher’s exact test. Furthermore, good communication versus lack of communication, cardiac compression depth, and frequency were analysed using the t-test and presented as the mean and SD. The significance level was set at P < 0.05. Statistical analysis was performed in IBM SPSS version 20. 3. Results The study included 18 EMDs who gave T-CPR instructions over the phone to 20 laypersons who performed CPR. The EMDs who participated in the study were predominantly women – 72% (n = 13) – and 11% (n = 2) of EMDs were registered nurses. The majority had worked for more than 5 years. The mean age of the laypersons was 66.8, and of them 65% (n = 13) were men. Ten laypersons had had CPR training more than six years ago, two laypersons had had such training 2–3 years prior, and eight laypersons had not had any training in CPR. Four laypersons had practical experience of CPR – see Table 1.

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Table 1 Background characteristics of emergency medical dispatchers (EMD) and laypersons Background characteristics of EMDs Sex: women/men Education: EMD/Registered Nurse Years at the dispatch centre < 5/ > 5 Latest CPR education < 3 months, n (%) < 6 months, n (%) < 1 year, n (%) > 1 year, n (%) Background characteristics of laypersons Age, mean ± SD Sex: women/men Former CPR course completed No course, n (%) 2–3 years ago, n (%) > 6 years, n (%) CPR experience No CPR experience, n (%) One time, n (%)

n = 18 13/5 16/2 7/11 n = 17* 5 (29.4) 3 (17.6) 1 (5.9) 8 (47.1) n = 20 67 ± 8 7/13 8 (40) 2 (10) 10 (50) 16 (80) 4 (20)

* Missing data for one EMD.

several other times during the call. In some conversations, the EMD repeated that help was on the way several times. Many EMDs asked the callers ‘Can you continue?’ or ‘Can you hold on?’ A recurring issue was whether they were alone or if they

Table 2 EMDs’ compliance with T-CPR instruction and action performed by laypersons. Correct instruction or partly correct (ruled-out parts of the instruction) = Correct. Instruction not given or given incorrectly = Incorrect. Action performed by layperson indicated with No and Yes. Action performed by layperson Created free airway

Compliance with T-CPR instruction by EMD n = 20

Place one hand on the forehead and the other hand under the chin of the patient and bend the head backwards. (Airway control instruction)

Incorrect Correct Total

No

Yes

13 5 18

2 0 2

3.1. Quantitative results When EMDs instructed with correct application of the T-CPR protocol, the laypersons performed the correct action 71% of the time (correct action of laypersons, 51 times; correct application of the protocol by EMD, 72 times). EMDs giving T-CPR instructions incorrectly had the outcome of the correct action being performed by the laypersons 28% of the time (correct action of laypersons, eight times/incorrect following of instructions by EMD, 28 times) – see Table 2. The most difficult instruction for an EMD to follow and for a layperson to perform was ‘Place one hand on the forehead and the other hand under the chin of the patient and bend the head backwards’ (airway control instruction). Only 25% of the EMDs managed to follow the instruction correctly, and only 10% of the laypersons could create a free airway. EMDs instructed airway control incorrectly 65% of the time, and 10% omitted the instruction entirely – see Table 2. Compliance with the instruction ‘Press straight down 30 times and count out loud in the pace: ONE-TWO-THREE-FOUR . . . 30 with a rate of 100 chest compressions per minute’ (chest compression instruction) was correct or partially correct by all EMDs. The instruction ‘Kneel down close to the upper part of the chest’ was incorrectly instructed in 15% of the cases, and 30% of EMDs gave no instruction at all. The results of laypersons’ performed actions showed that 60% of the laypersons had positioned themselves correctly on their knees close to the upper part of the person’s chest, and 95% had achieved the proper hand placement. Eighty-five percent of the laypersons performed the action with straight arms, and 45% counted aloud during the execution – see Table 2. Results based on individual instruction, regardless of whether the EMD had followed the instruction correctly or incorrectly, showed no statistical difference in the quality of the actions performed by the laypersons – see Table 2. 3.2. Qualitative results The qualitative content analysis resulted in two categories – good communication and lack of communication – and four subcategories – see Table 3. 3.2.1. Good communication 3.2.1.1. Acknowledgement of the caller’s situation. In all talks between the EMD and the caller, it was found that he or she would get help and/or that there was an ambulance on the way. Usually, the information was given at the beginning of the conversation and at

Total

p-Value

15 5 20

1.00

Body position

Kneel down close to the upper part of the chest.

Incorrect Correct Total

No

Yes

6 2 8

3 9 12

9 11 20

0.065

4 16 20

0.200

Proper hand placement

Put your hands on top of each other on the chest, between the nipples.

Incorrect Correct Total

No

Yes

1 0 1

3 16 19

Pressed with straight arms

Press straight down 30 times and count out loud at the pace: ONETWO-THREEFOUR . . . 30, with a rate of 100 chest compressions per minute. (Chest compression instruction)

Incorrect Correct Total

No

Yes

0 3 3

0 17 17

* 20 20

Counted out loud during chest compressions

Press straight down 30 times and count out loud at the pace: ONE-TWOTHREEFOUR . . . 30, with a rate of 100 chest compressions per minute. (Chest compression instruction)

Incorrect Correct Total

No

Yes

0 11 11

0 9 9

0 20 20

*

* p-Value, immeasurable; all EMDs carried out the instruction correctly.

H. Nord-Ljungquist et al./International Emergency Nursing 23 (2015) 254–259

Table 3 Categories and subcategories in the structural analysis Categories

Subcategories

Good communication

Acknowledgement of the caller’s situation Interaction in the communication Unclear instructions Lack of interaction in the communication

Lack of communication

have anyone else there who could help them. To encourage the callers to continued CPR, the EMDs used the expressions ‘That was great done!’ or ‘Good!’. 3.2.1.2. Interaction in communication. Interaction in communication between the EMDs and the caller was very clear in multiple calls. The caller verified what they did or what they would do. Some EMDs ensured the instructions they provided were understood or being carried out. EMD: You are on your knees at her side? The caller: Yes. EMD: At chest level? Communication between the EMD and the caller facilitated when there was some kind of feedback with small words eg. um, hmm between them. The callers often said only one word like ‘hmm’ or ‘yes’ and that encouraged the EMDs to give further information about what the callers should do. The answer from the callers’ gave the EMD feedback often with ‘hmm’ or ‘yes’. EMD: She’s lying on her back now? The caller: Yes. EMD: Yes. The handling of the telephone was given either as an instruction from the EMD or the caller said how he or she intends to managed the phone. If the caller had a problem with the handling of the phone, he or she explained this to the EMD. 3.2.2. Lack of communication 3.2.2.1. Unclear instructions. Communication between the EMD and the caller was difficult if the instructions were not compliant to the protocol or was not clear enough and the EMD selected their own phrases. This was also noticeable when there were questions, instructions and claim in the same sentence. Some instructions that were given were complex or the EMD added an additional question that the caller tried to answer. The written statement under the T-CPR protocol reads: ‘Then you need to open the airway. Place the patient on his back’. The spoken instruction was: ‘EMD: But what you have to do now is to try to hear whether or not he is breathing, so you have to open your husband’s airway. He’s on his back now?’ The written statement under the T-CPR protocol reads: ‘Listen for the patient’s breathing’. The spoken instruction was: ‘EMD: Try to do what it says . . . She is totally unconscious. Can you hear her breathing?’ The written statement under the T-CPR protocol reads: ‘Undo his shirt over the chest and see if the chest is rising’. The spoken instruction was: ‘EMD: Is he wearing a lot of clothing? The caller: He’s just wearing a light jacket and pants. EMD: Undo the snaps on the front of the jacket and pull the jacket open. The caller: Yes. EMD: I’ll wait while you loosen up his clothing a bit.’ 3.2.2.2. Lack of interaction in communication. When the dialogue between the EMD and the caller was insufficient, there were various possible reasons. One of these was when the callers did not hear instructions, because they had already put down the phone and started an activity. The EMD often continued to give the instruc-

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tions without knowing this. After a few seconds, the EMD surmised that no one was listening when there was no feedback and shouting “Hello”, or when confirmation in the form of small words like ‘hmm’ or ‘yes,’ did not exist in the conversation. Sometimes the EMD tried to wait for verbal or non-verbal communication over the phone. EMD: So you stand with straight arms and press the chest and press, take in and press down quite so hard on her, then do 30 presses fairly quickly – 1–2-3–4 [silence] The caller: [Silence from the caller, begins the CPR.] EMD: Hey! The dialogue between the callers and the EMD was not always optimal: for example, sometimes the callers asked questions and wanted to be able to handle the situation, but the EMD interrupted the caller and/or gave no constructive response. The caller: What should I . . .? EMD: [interrupting the caller] hmm, don’t hang up, you should start with. . . hmm, what’s it called. . . The caller: She’s not breathing! 3.3. Merging results from quantitative and qualitative analyses The qualitative category of good communication was represented in eight calls and the qualitative category of lack of communication was represented in 12 calls. These results were put into dichotomous variables and were assembled with the results of quantitative analysis – see Table 4. The results showed no statistical difference regarding performed actions and the quality of CPR by laypersons, regardless of whether there was a good communication or a lack of communication with the EMD. The mean values for chest compression depth and frequency did not reach recommended guidelines for CPR – see Table 4. 4. Discussion The purpose of this study was to describe compliance with the T-CPR protocol, the communication between the EMDs and the laypersons, and the results of instructions given in a simulated T-CPR situation. The results showed that there were no differences in the actions performed or quality of CPR by laypersons, whether there was good communication or a lack of communication with the EMDs. Research on communication between healthcare professionals and

Table 4 CPR action and quality based on a lack of communication and on good communication, respectively n = 20

Lack of communication 12

Good communication 8

Action

Yes

No

Yes

No

1 8

11 4

1 4

7 4

1.000 0.648

11

1

0

8

1.000

6

6

5

3

0.670

10

2

7

1

1.000

Creating free airway Body position (kneeling down close to the upper part of the chest) Proper hand position (putting your hands on top of each other on the chest, between the nipples) Counting out loud at the performance of chest compressions Pressing with straight arms during execution of chest compressions CPR quality n = 19*

11

8

Chest compressions depth (mm), mean ± SD Chest compressions (n/min), mean ± SD

36.6 ± 11.3 61 ± 20

35.5 ± 18.4 64 ± 37

p-Value

0.894 0.800

* A registry record of Laerdals CPR doll Anne, PC Skillreporting is missing.

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patients has shown that measurement of communication may be impaired because of the interrelationships of behaviour, meaning, and the significance and complexity of the evaluations (Street, 2013). The qualitative content analysis showed the importance of the acknowledgement of the caller’s situation and interactions that together led to good communication between the EMD and the caller. While a caller waits for an ambulance the EMDs can by phone convey a sense of security and provide assurance to the caller that help is on the way (Ahl et al., 2006; Forslund et al., 2005). Good interaction between the EMD and the caller can mean unprejudiced listening, the ability to be empathetic and supportive, and the ability to give mental strength so that the layperson is able to act in an emergency situation (Bång et al., 2002). The qualitative results showed if unclear instructions or a lack of interaction in the communication occurred led to a lack of communication in the encounter between the EMD and the caller. Previous research has shown that a lack of communication can occur in an emergency call, depending on the emotional state of the caller – whether he or she is emotional, excited, or talking too quickly when speaking with an EMD (Higgins et al., 2001). This results in unclear instructions, which can be interpreted as the EMD’s uncertainty or lack of experience in giving T-CPR instructions. Forslund et al. (2004) have shown that skills, knowledge, and experience are important factors in an EMD’s work. The results of a lack of interaction in communication appeared when the EMDs failed to give specific answers to questions or used non-words like ‘hmm’ or ‘mm’. A lack of communication can occur when the message is not received or is misunderstood because the layperson fails to listen actively, or may be reflected how the message is given. It is important that the message be understood by all involved (Travelbee, 1971). Results based on individual instruction, regardless of whether the EMD was in correct or incorrect application of the T-CPR protocol, did not increase the quality of the actions performed by laypersons. Correct application of the T-CPR protocol is important, however, if the action performed is to be correct. This indicates how important it is that T-CPR protocols exist and that the instructions are followed completely. When an EMD applies the T-CPR incorrectly, but the correct action is taken by the caller, even if to a lesser extent, the result may depend on whether the layperson who performs the action has had previous experience or training in CPR. The EMD’s T-CPR skills depend on that person’s training, number of T-CPR calls he or she has dealt with, and feedback he or she has received on patient treatment outcomes. Research has shown a correlation between the number of calls managed by an EMD in a given period being low and a decreased probability of patients’ survival (Kuisma et al., 2005). The lack of a standardized reporting system among EMCCs creates difficulties in evaluating the actions carried out by the EMD (Castrén et al., 2011). The instruction that was the most difficult to perform was airway control, and only 25% of the EMDs did this correctly or partially correctly. An earlier study has confirmed that the airway control took the longest time to complete in the conversation between the caller and the dispatcher (Clegg et al., 2014). Compliance with the instruction may depend on the EMD’s experience of T-CPR calls, even if the instructions are formulated incorrectly. The EMD is also dependent on the knowledge and trustworthiness of the layperson. Convincing answers from the laypersons provide the EMD with feeling of reassurance (Bång et al., 2002; Forslund et al., 2004). The laypersons also had trouble following this instruction: only 10% were able to create a free airway. Simplified T-CPR instructions, without airway control, given to laypersons in a simulated CPR situation resulted in significant reductions in time-to-first-compression and improvements in compression depth (Painter et al., 2014). Every minute is precious for the person who has an OHCA. Every minute that passes without CPR corresponds to a more than 5% reduction in the survival rate (Larsen et al., 1993).

The mean values for chest compression depth and frequency did not reach established guideline goals for CPR (Nolan et al., 2010). This shows the complexity of providing T-CPR instructions and implementing these instructions. Simplified T-CPR protocols have previously been evaluated to improve the quality of chest compressions. One study tested a simple instruction – ‘Push as hard as you can’ – and compared it with ‘Press down approximately 5 cm’. The results of that study showed that ‘Push as hard as you can’ still led to an average chest compression depth under international guidelines (Mirza et al., 2008). In another study comparing two protocols, the simpler protocol got the best result on nearly all of the variables, but not on the hand placement on the chest (Dias et al., 2007). The difference between undressing the patient’s upper body before performing chest compressions, as the current instruction demands, or leave clothing on has also been evaluated. The results showed that the quality of chest compressions was unaffected if the clothes were left on. The authors’ conclusion was that taking the patient’ clothes off before performing chest compressions was unnecessary in the T-CPR protocol. Important time can be saved by dispensing with this step, and survival can be improved (Eisenberg Chavez et al., 2013). A Hawthorn effect may have influenced the results. To avoid this as far as possible, the EMDs were in their normal working environment and were instructed to treat the phone call as a real situation as far as possible. Other weaknesses of the study are that the laypersons who performed CPR in a simulation were probably calmer than they would have been in a real life situation. Finally, it must be taken into account that this was a pilot study and the number of participants was small, particularly as regards the quantitative section. This is the first study in this field that has employed a mixed method with convergent parallel design. The rationale for combining quantitative and qualitative methods is that it represents an attempt to obtain a deeper understanding and description of a very complex situation using a scientific approach (Creswell and Plano, 2011). The reliability of the study is strengthened by both audio and video files that showed how the T-CPR protocol was applied and the communication between the EMD and the caller. As well as, the measured values from Laerdal PC Skillreporting have been analyzed and reported. The study’s reliability was further substantiated by the participation of a third person with specialist knowledge who assessed the films in cases where there was a discrepancy in the evaluations made by the two authors. The same aim was used for both the quantitative and the qualitative data collection to achieve greater validity (Creswell and Plano, 2011). The authors continuously considered and made comparisons between codes, subcategories, and categories, to arrive at a consensus interpretation and to increase the trustworthiness of the analysis (Graneheim and Lundman, 2004). This was a pilot study, and the number of participants was small. It would be interesting to try a similar model of analysis with a larger contributor base, especially regarding the quantitative section, and to create a questionnaire that could be used to evaluate a large number of calls based on the qualitative results. This could lead to quality assurance and development of a future T-CPR protocol. The potential implication of the study for practice is to clarify the difficulties involved for laypersons in following instructions by telephone. For better results, it is important to know how we can optimize the training of EMDs and how to develop the instructions in the protocol. This kind of study shows us these variables. 5. Conclusions Correct EMD application of a T-CPR protocol resulted in better performance of CPR by laypersons. The most problematic area for EMDs, and for laypersons to perform, was airway management. The study results did not establish that the quality of the

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Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (CPR): A mixed-methods study of simulated telephone-assisted CPR.

In the event of a cardiac arrest, emergency medical dispatchers (EMDs) play a critical role by providing telephone-assisted cardiopulmonary resuscitat...
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