Clinical
paper
Dispatcher-assisted
cardiopulmonary
resuscitation
for
paediatric
out-of-hospital
cardiac
arrest:
A
structured
evaluation
of
communication
issues
using
the
SACCIA
1safe
communication
typology
Jen
Heng
Pek
a,
Dirk
Frans
de
Korne
b,c,d,*
,
Annegret
Friederike
Hannawa
e,
Benjamin
Siew
Hong
Leong
f,
Yih
Yng
Ng
g,
Shalini
Arulanandam
h,
Lai
Peng
Tham
i,
Marcus
Eng
Hock
Ong
j,c,
Gene
Yong-Kwang
Ong
ka
AcuteCareClinic,DepartmentofMedicine,SengkangHealth,110SengkangEastWay,Singapore544886,Singapore
b
MedicalInnovation&CareTransformation,KKWomen’s&Children’sHospital,100BukitTimahRoad,229899,Singapore
c
HealthServices&SystemsResearch,Duke-NUSMedicalSchool,8CollegeRoad,Singapore169857,Singapore
dHealthServicesManagement&Organisation,ErasmusSchoolofHealthPolicy&Management,ErasmusUniversityRotterdam,Burgemeester
Oudlaan50,3062PA,Rotterdam,TheNetherlands
e
CentreforAdvancementofHealthcareQualityandPatientSafety,FacultyofCommunicationSciences,UniversitadellaSvizzeraitaliana,
ViaBuffi13,6900Lugano,Switzerland
f
EmergencyMedicineDepartment,NationalUniversityHospital,5LowerKentRidgeRoad,Singapore119074,Singapore
gEmergencyDepartment,TanTockSengHospital,11JlnTanTockSeng,Singapore308433,Singapore
hMedicalDepartment,SingaporeCivilDefenceForce,91UbiAvenue4,Singapore408827,Singapore
iDepartmentofEmergencyMedicine,KKWomen’s&Children’sHospital,100BukitTimahRoad,Singapore
j
DepartmentofEmergencyMedicine,SingaporeGeneralHospital,1HospitalDrive,169608Singapore
k
DepartmentofEmergencyMedicine,KKWomen’s&Children’sHospital,100BukitTimahRoad,229899Singapore
* Correspondingauthorat:KKWomen’s&Children’sHospital,100BukitTimahRoad,Singapore229899,Singapore.
E-mailaddresses:pek.jen.heng@singhealth.com.sg(J.H.Pek),dirk.de.korne@kkh.com.sg,dirk.dekorne@duke-nus.edu.sg,
dekorne@eshpm.eur.nl(D.F.deKorne),annegret.hannawa@usi.ch(A.F.Hannawa),Benjamin_sh_leong@nuhs.edu.sg(B.S.H.Leong),
yih_yng_ng@ttsh.com.sg(Y.Y.Ng),shalini_arulanandam@scdf.gov.sg(S.Arulanandam),tham.lai.peng@singhealth.com.sg(L.P.Tham),
Marcus.ong.e.h@singhealth.com.sg,marcus.ong@duke-nus.edu.sg(M.E.H.Ong),gene.ong.y.k@singhealth.com.sg(G.Y.-K.Ong).
https://doi.org/10.1016/j.resuscitation.2019.04.009
Received25January2019;Receivedinrevisedform18March2019;Accepted3April2019
0300-9572/©2019ElsevierB.V.Allrightsreserved.
Available
online
at
www.sciencedirect.com
Resuscitation
Abstract
Aim:Toevaluatecommunicationissuesduringdispatcher-assistedcardiopulmonaryresuscitation(DACPR)forpaediatricout-of-hospitalcardiac
arrestinastructuredmannertofacilitaterecommendationsfortrainingimprovement.
Methods: A retrospective observational studyevaluated DACPR communication issues using theSACCIA1 Safe Communicationtypology
(Sufficiency,Accuracy,Clarity,Contextualization,Interpersonal Adaptation).Telephonerecordingsof31 casesweretranscribedverbatimand
analysedwithrespecttoencoding,decodingandtransactionalcommunicationissues.
Results:SixtySACCIAcommunicationissueswereobservedinthe31cases,averaging1.9issuespercase.Amajorityoftheissueswererelatedto
sufficiency(35%)andaccuracy(35%)ofcommunicationbetweendispatcherandcaller.SituationspecificguidelineapplicationwasobservedinCPR
practice,(co)countingandmethodsofcompressions.
Conclusion:ThisstructuredevaluationidentifiedspecificissuesinpaediatricDACPRcommunication.Ourtrainingrecommendationsfocuson
situationandlanguagespecificguidelineapplicationandmovingbeyondverbalcommunicationbyutilizingthesmartphone’sfunctions.Prospective
effortsarenecessarytofollow-upitstranslationintobetterpaediatricDACPRoutcomes.
Keywords:Cardiacarrest,Cardiopulmonaryresuscitation,SACCIA,Safety,Communication,Dispatcher-assisted,Paediatric
Introduction
The outcome of paediatric out-of-hospital cardiacarrest (OHCA)
is dismal with survival rates ranging from 3 to 17%.1,2 Early
commencement of cardiopulmonary resuscitation (CPR) by
by-standersforpaediatricOHCAhasbeenshowntoimproveoverall
andneurologicallyfavourablesurvival.3–5However,theperformance
ofbystander CPRin paediatricOHCA(vs. non-performance)has
been variable across different countries, ranging from 23% in
Singapore to 35% in North America and 53% in Japan.4–7
Dispatcher-assistedCPR (DACPR) isan effectivestrategywhich
hasbeenshowntoincreasetheperformanceofbystanderCPRand
alsosurvivalfromOHCA.4,5,8–10WhenacalleractivatesEmergency
Medical Service (EMS), in addition to dispatching ambulance to
scene,thedispatcher, asthefirstprofessional contactforcardiac
arrest,isabletoaidtherecognitionofcardiacarrestbyelicitingkey
informationandprovideguidancetothecaller.Asimple,two-question
algorithm (Fig. 1) is used sothat the first chest compression is
deliveredwithinsecondsofthecallforhelp.8Callersareinstructedto
putthephoneonspeakermodetofacilitateDACPRinstruction.
InSingapore,anadultDACPRprotocolwasintroducedin2009
andthebystanderCPRratesincreasedfrom19.7%to22.4%from
2009to2012.11Subsequently,aDACPRbundleconsistingofDACPR
protocol for adult and paediatric OHCA, dispatcher training,
systematicqualityimprovementthroughreviewofalldispatchcalls,
andpubliceducationcampaignaroundDACPR,wereimplemented
underthePan-Asian Resuscitation Outcomes Study(PAROS)II,
equippingandempoweringalldispatcherstoprovideDACPR.12,13
However, executionofDACPRisoperationallychallenging.Inan
earlier study, barriers which delayed and prevented successful
compressionswereidentified.14Amongstthelistofcommunication
barriers,‘Calleroverlydistraught’,‘Language’,‘Qualityofinstructions’
and‘Technicaldifficulties’werereportedchallengesrelatedtothe
provisionofDACPR.Otherbarrierswererelatedtotheuseofthe
phone,thelocationofthecallerandthepositionofthepatient.14
Paediatric DACPR communication is inherently challenging
becauseitrequiresidentificationofpaediatricarrestoverthephone
and the provisionof complex verbalCPR instructions (i.e.chest
compressionswithventilationascomparedtoadoptionofhands-only
CPRinstructionsforadults).Asremoteinstructionsaregiven,the
dispatcherhasminimalfeedbackontheactualdeliveryandqualityof
therescuer’sCPRrenderedtothevictims.Littleisknownaboutthe
factorsfacilitating andhinderingcommunicationduring DACPRin
both adult and paediatric populations. Given its complexity, we
hypothesizethatcommoncommunicationerrorsoccurinpaediatric
DACPR.Toinformthishypothesis,weneedasystematicexamination
oftheinterpersonalcommunicationinthecontextofDACPRtoidentify
issues that affect transmission, receipt, translation and feedback
duringtheprocess.
Inthisstudy,weaimtoevaluatecommunicationissuesduring
DACPR for paediatric out-of-hospital cardiac arrest to facilitate
recommendationsfortrainingimprovementusinganovel
evidence-basedcategorizationschemeforsafehealthcarecommunication.15
Methods
Setting
InSingapore,adensemulti-ethniccitystateof5.6millioninhabitants,16
EMS is primarily provided by the Singapore Civil Defence Force
(SCDF), withaminority ofprivateambulance operators.SCDF,which is
thenationalFire,RescueandEmergencyMedicalResponseAgency,
dispatchesambulancesandfirst-respondermotorcyclesinresponseto
medicalcalls.ActivationofEMSisbycalling995toacentralized
dispatch centre, which utilizes computer aided dispatch protocols
(usingthePowerPhonesystemwhichallowsmodificationtoexisting
protocolsandsupportsthe‘no,no,go’methodology),aglobalposition
satelliteautomaticvehiclelocationsystemandroadtrafficmonitoring
systemstooptimiseoperations.Thisserviceisfreetoallemergency
callers and supported through government taxes. SCDF employs
dispatchers whoarealltrainedinDACPR.Inaddition,nursesare
employedtorunqualityassuranceandimprovementprograms,aswell
Fig.1–AlgorithmforrecognitionofcardiacarrestbyEMS
astoprovideadditionalnursingadvicewhennecessary.TheDACPR
instructiontemplateisdescribedinFig.2.
Studypopulationanddesign
Weconductedaretrospectiveobservationalstudy.Casesofpediatric
cardiacarrestwereretrievedfromaregistryunder PAROS,which
includedallcasesofOHCAidentifiedbytheparamediconscene.Data
wascollectedfromambulancerecordsandaudiofileswiththetwo-way
telephonerecordingsoftheDACPRperformancebetweendispatcher
andcallerusing standardizedformsforallpaediatricOHCAcases
handledbytheSCDF dispatchcentrefrom1January2014to31
December2015.Paediatriccases weredefined byage16years orless.
Datafieldspertainingtodemographics,instructionandperformanceof
DACPR,aswellasclinicalcourseandoutcomeswerecollected.
Theoreticalframework
WeusedtheSACCIA1TypologyofSafeCommunicationin
Health-care arecentfirstevidence-based categorizationschemeforsafe
healthcarecommunicationthatlendsitselfforanalysing
communica-tion issues in paediatric DACPR situations.15 According to the
SACCIAframework,safeandhigh-qualityDACPRcommunication
encompasses “allverbalandnon-verbal behaviours that, through
adequatequantityandquality,optimizethelikelihoodofdeliveringthe
most appropriate and effective outcomes”.15 The letters in the
acronym“SACCIA”standforfivecommontypesofcommunication
errors:Sufficiency,Accuracy,Clarity,Contextualizationand
Interper-sonalAdaptation.15Theseerrorstranspireacrossthree
communica-tionprocesses:duringDACPR,thecalleranddispatcher(1)encode
theirownthoughts,feelingsandintentionsintowordsandactions,
Fig.2–InstructiontemplateforDACPR.
Table1–SACCIA1principlesforsafecommunication.17
Principle Implication
Communicationiscontextual Meaningofamessageisalwaysinfluencedbythecontextinwhichinteractiontakes place.
Redundancyincontentanddirectnessinchannelenhanceaccuracy Likelihoodofattainingsharedunderstandingincreaseswhencareparticipants repeatmessagecontentappropriatelythroughdirectratherthanindirectmeans. Communicationisanon-summativeprocess Communicationisaninteractiveprocesswhosegoalinhealthcareistoreachastate
ofsharedunderstanding.
Preconceptionsandperceptionsvaryamongcommunicators Careparticipantsenteranygivencareepisodewithdifferentpreconceptionsand willperceivetheircommunicationdifferently.
Communicationentailsfactualandrelationalinformation Communicationalwaysconveysbothfactualandrelationalinformation. Communicationvariesbetweenthought,symbolandreferent Humans‘makemeaning’throughthecreationanduseofsymbols(e.g.words,
gestures,sounds).
Communicationismorethanwords Verbalmessagesarealwaysaccompaniedbynonverbalbehavioursorexpressions thatincludevisibleandvocalcues.
(2)decodereceivedmessagesinanefforttoreplicatethesender’s
intended thoughts, feelings, or intentions and (3) engage in
transactional(i.e.dyadic)communicationtojointlygenerateashared
understanding.15 Beyond identifying communication errors, the
SACCIAframeworkfurtherallowsforanevidence-basedrootcause
analysisthattracesthereasonsforsucherrorstosevencommon
misassumptions about human communication.17 These seven
“SACCIA root cause principles” are defined and summarized in
Table1.
Datamanagementandanalysis
Fourresearchersindependentlyidentifiedandscoredthe
communi-cationissuesfromtheaudiofiles.AFH,anexpertincommunication
sciencesandco-founderoftheSACCIA1 framework,has trained
theotherthreeresearcherswhohaveabackgroundinemergency
medicine(JHP,GO)andhealthservicesresearch(DFK).Recordings
of theaudio files were played back in a dedicated controlroom
on SCDF premise by SCDF staff. Researchers noted down the
communicationsverbatimandclassifiedtheissuesraisedaccordingly
to theSACCIA1 Typology. Differences in classification were
dis-cussedandanoverallagreedscoringplotwasanalysedastherecould
beoverlapbetweenthecommunicationerrorcategories.Theseven
SACCIA principles of communication were used for root cause
analysis.SCDF’sDACPRexpertsreviewedandcommentedonthe
differentdrafts.
Thisstudyreceivedethicalapprovalandwasgrantedawaiverof
patientconsent(CIRB2013/604/CandDSRB2013/00939).
Results
Cohortcharacteristics
Therewere 51 paediatric OHCAs in thestudy period.Available
audiofileswereretrievedandmatched31(61%)cases.DACPR
was initiated in 15 (48%) cases. The remaining cases did not
receive DACPR due to ongoing bystander CPR at time of call
(n=10),callernotatscene(n=4)andpatientnotincardiacarrest
at time of call (n=2). Of the 15 caseswith DACPR, 12 (80%)
translatedintoactualperformanceofDACPRbythecaller.One
callerdidnotperformdespiteinstruction.Fortheother2cases,the
ambulancearrived priortocommencementofCPR bythecaller
(seeFig.3).
Communicationissues
In total,60communicationissueswereidentifiedacrossthe31
cases,averaging 1.9SACCIAincidentspercall.Majority ofthe
issues were related to sufficiency (n=21, 35%) and accuracy
(n=21,35%)ofinformation.Thirteenpercent(n=8)wasrelatedto
contextualisation, 10% (n=6) to clarity and the remaining 7%
(n=4) to interpersonal adaptation. Encoding of messages by
dispatcherswascommonlycompromisedbyinsufficient
informa-tional content (n=14, 23%). Transactional communication
be-tween dispatchers and callers lacked accuracy (n=11, 18%).
Decoding of messages was also inaccurate (n=4, 7%). See
Table2forexamples.
SACCIAprinciples
TheaboveissuesinDACPRwerefurtherclassifiedintotheseven
SACCIArootcauseprinciplesofhumancommunication,17orderedby
theirfrequencyofoccurrenceinourdataset:
Principle1:redundancyincontentanddirectnessinchannel
enhanceaccuracy
This principle postulates that the likelihood of attaining shared
understanding increases when the dispatcher and caller repeat
message content appropriately (i.e. when it aids transmission of
informationbutnotunnecessarilyoften)throughdirectratherthan
indirectmeans.Althoughcontinuouscountingofchestcompressions
togetherbythecalleranddispatcherwasspecifiedintheprotocol,
callerswerenotcountingoutloudnorweretheyinstructedtodosoin
mostofthecases(94%).Onedispatchergaveinstructionstoperform
compressions,butdidnotindicateto“pumphardandfast”nordid
mention thedepth of compressionor instructthisusing different
verbatim. This resulted in the rescuer having to ask for further
instructions. Repeated requests or reminders to co-count could
contribute toguidelineadherence.Inothercases,however,there
seemedtobeanover-useofredundancy.Forexample,inonecasea
dispatcher said: “Hello.Hello.You understand, you understand?”
Wordsandsentences wererepeatedunnecessarily.Thus,
redun-dancy isan essentialaccuracy-promoting interpersonal validation
process,butitmustbeusedappropriately.
Principle2:communicationisfunctional
Somecommunicationissuesinthisstudywererelatedtothefunction
oftheDACPRprotocol.Compression-onlyCPRwasinstructedin80%
of thecases,althoughtheprotocolstatedconventionalCPR with
chest compression and ventilation for paediatric cases. We had
observed instances wheninstructions forconventional CPRwere
given, the ratio of chestcompression to ventilationdiffered from
protocol. Therateofcompressionwas inadequatein 73%ofthe
cases, all falling below 100 compressions per minute. In one
Table2–SACCIA1categorizationofDACPRcommunicationissueswithexamples.
Category N(%) Type(%) Exemplaryissuesfound Recommendedareasfor
improvement
Sufficiency 21(35%) Encoding(23%) Thedispatcherdoesnotelaboratewhethersomeoneelseatthescene couldbecontactedforperformingDACPR.
Toconveyencompassing infor-mation.
Thedispatcherreferstotheuseofthemiddleandringfingers,butdoesnot indicatetheintensityofcompressions.
Transactional (10%)
Theinstructorasksthecallertoco-count,butnoco-countingisaudible. Theinstructorrepeatshisrequestoncemoreandcontinuestocount himself.
Toincreaseinformational follow-upandassistanceforthecaller. Uponstartofthecall,CPRisalreadyongoingonastudentwhodrownedat
aswimmingpool.ThereisnocheckonthequalityoftheongoingCPR,and nodispatcherguidanceorassistance.
Decoding(2%) Thedispatcherdoesnotaskfortheageofthepatientbutsimplyappliesan adultalgorithm.
Toextractenoughpatient information.
Accuracy 21(35%) Encoding(10%) Toidentifythegeographicallocation,theblocknumberisaskedinsteadof thepostalcode(whichisindicatedinthetemplate).
Toprovideinformationin align-mentwiththeprotocolor guidelines.
ThedispatcherindicatesthatCPRcouldbesloweddownabit,whilethe ratewasactuallygoingok.
CPRisperformedwith15compressionsand2breaths,whiletheprotocol states30compressionand2breaths.
Transactional (18%)
Thecallerindicatesthatthebabyisvomitingoutmilk.Thedispatcher assumesthatthismustblockpotentialairflowandinstructstoputthebaby facingdownwardsandtapattheback5times.
Toengageinterpersonal com-municationasamechanismto validatetheaccuracyof treat-mentsandprocesses. TheIndianlanguage/dialectusedbythecallercausesa
misunder-standingbythedispatcher.
Decoding(7%) Thecallersaystothedispatcher"Heisgone."Shereferstotheperson whowaspreviouslyintheroom.Thedispatcherhoweverthinksthatit referstothepatientandtriestomotivatehertocontinueCPR(“Don'tgive up”).
Todrawcorrectconclusionsand tobecarefulaboutaccurate messageinterpretations. Clarity 6(10%) Encoding(7%) ThereportedroadisCendingRoad,butthedispatcherisnotabletolocate
it.AlongdiscussiononCending('cashew')orPending('potato')starts. Finally,thedispatcherconfirmsthatitmustbePendingRoad,closetothe BukitPanjangRingRoad.
Touseclearlanguageand pro-videclearinstructions.
Thefirstcallerisnotatthesceneandcannotgivedetails('Don'tknowlah'), whilethedispatcherassumesthatheisatthescene.
Transactional (2%)
ThedispatcheraskswhetherCPRisbeingperformed,butinitiallythereis noanswer.Thebystanderdidnotunderstandwhatthedispatcherasked.
Toengageinterpersonal com-municationasamechanismfor reducinguncertaintyand clarify-ingmessagecontent
Decoding(2%) Thedispatcherindicates"Ineedyoutodo100beatsperminute"insteadof"at least100perminute",andisunclearforthecallerwhatthisrateentails. Contextualisation 8(13%) Encoding(6%) Theagentaskswhathappenedfirst,beforeaskingfortheaddressofthe
scene.
Tousecommunicationfor con-textualizingtheremotesetting andpatientsituation. Transactional
(7%)
Thecallersaystothedispatcher"Heisgone."Shereferstotheperson whowaspreviouslyintheroom.Thedispatcherhoweverthinksthatis referstothepatientandtriestomotivatehertocontinueCPR('Don'tgive up').
Toengagecommunicationfor context-basedcoordination.
Thepersonsays'Iamverytired'afteracoupleofminutesofperforming CPR.Thedispatcherdoesnotaskwhetherasecondpersonisavailableto takeovertheCPR
Interpersonal adaptation
4(7%) Encoding(3%) Thedispatchersays:"Hello.Hello.Youunderstand,youunderstand?" Wordsandsentencesarerepeatedandthetoneisconfrontational.
Topayattentionto relationship-buildingcommunication, partic-ularlytononverbal“vocalics” (e.g.toneandinflectionofvoice, speakingrate),becausethey conveyasmuchinformationas whatissaid.
Transactional (2%)
Whileco-countinghappens,duringthecourseofCPRno encourage-mentsorconfirmationofqualityoftheCPRisgiven.
Toprovideinterpersonally adaptive(i.e.needs-based) en-couragementsduringCPR. Decoding(2%) Thecallercomplainsmultipletimesthatittakessuchalongtimeforthe
ambulancetoarrive.Onlyafterawhile,thedispatcherindicatesthatthe ambulancecomesfromTampines.
Torecognizeandrespondtothe caller’sexpressedneedsand expectationsduringtheCPR
encounter,thedispatcheraskedtoslowdownthechestcompression
ratewhenitwaswithintherecommended100–120compressions
perminute.Differentcountingmethodswereobserved,from“1,2,3,4,
5, ...,10;2,2,3,4,5...,10, ...”to“1,2,3,4,5, ...,30”in10
casesand“1and2and3and4and5,1and2and3and4and10, ...
and30”in1case,anditwasunclearwhetherthedispatcherswerestill
abletoachievetheintendedrates.Communicationpursuesvarious
functionsbutthemainfunctionofDACPRmustpursuethefunctionof
protocoladherencetomaximizesafetyandoutcomes.
Principle3:preconceptionsandperceptionsvaryamong
communicators
Thisprincipleofhumancommunicationstatesthatdispatcherand
callerentertheircallwithdifferentpreconceptionsandwillperceive
eachother’scommunicationdifferently.Thisalsoappliestowritten
communication,wheresuchpreconceptionsmanifestthemselvesin
writtenscripts.Twelvepercentoftheissueswefoundevidenceda
“commongroundfallacy”:boththedispatcherandthecallergenerally
assumedthattheywillunderstandwhattheytelloneanother.15For
example,adispatcherdidnotgiveinstructionsforthepositioningof
thefingers.Thecallerneededtoask"IwonderwhereIdopress?"
resultingintimeloss.Recognitionofthissafety-compromisingfallacy
is critical. Transactional communication that pursues a shared
understandingisthepathwaytopreventingsuchmisunderstandings.
Principle4:communicationiscontextual
WhilethesettingofDACPRistosomeextentstraightforwardasthere
areonlytwopersonsinvolvedinthecommunicationprocess, the
meaningofamessageisalwaysinfluencedbythecontextinwhich
theinteractiontakesplace.Inonecase,thecallersaid,“Iamverytired”
afteracoupleofminutesofperformingCPR.Thedispatchermight
haverecordedtheactualfactbutdidnotcontextualizeittothesituation
inwhichthecallerwaspositioned,anddidnotfollow-upwith
safety-enhancingactions(e.g.askwhetherasecondpersonwasavailableto
takeovertheCPR).
Principle5:communicationvariesbetweenthought,symbol,
andreferent
Humans“makemeaning”throughthecreationanduseofsymbols
(e.g.,words,gestures,sounds,images,artefacts).Thisprocessis
construed through triangular associations: a referent (e.g., “the
patient”)isconnectedtoathought(i.e.,acognitiveassociationwith
theword “thepatient”), which again isrepresented bya chosen
vocabulary(e.g.,“thebaby”or“Paul”).Duringonecall,thedispatcher
heardthesoundofacryingbabyinthebackgroundandasked,“Isthe
babycrying?”Thefatheranswered,“No,that'smyotherdaughter.”In
anothercase,thecallersaid,“Heisgone”,with‘he’referringtoathird
partypresentatthescene(i.e.theintendedthoughtwas“hehasleft”),
but the dispatcher thought “he” referenced the victim (i.e. the
misunderstoodthought was“he hasdied”)andthuscontinuedto
encourage the caller by saying, “don’t give up” which caused
confusion during the DACPR process. In a phone-only way of
DACPRcommunication,thiskindofmisinterpretationofasingleword
orphraseconstitutesacommonthreattosuccessfulDACPR.
Principle6:communicationismorethanwords
Inface-to-facecommunication,verbalmessagesarealways
accom-panied bynonverbal behaviours such asvisible and vocalcues,
gesturesandtoneofvoice.InthecontextofDACPR,decodingofsuch
nonverbal communication islimited. In one case, the dispatcher
neededtorepeatquestionsmultipletimes(“howold,howold,girl,how
old”).Inadditiontothewordsthedispatcherwassaying,thetone,
tempo,andvolumeconstitutednon-verbalmessagesthatwerebeing
communicated andperceived asconfrontational.Thiscreated an
interpersonal barrier between the caller and the dispatcher and
discouragedthecallerfromcooperatingwithfurtherquestions.Inthe
dispatchercentre,onlyaudiocommunicationsareavailable,andthere
is no visual feedback to thedispatcher. However, such vocalics
constituteamaininformationcarrier:significantlymoremeaningis
attributedtononverbal (ratherthanverbal)communication.
There-fore,theimportanceofvocalics(i.e.theuseofthevoicesuchastone,
volume,speedetc.)forsafeDACPRiscriticaltorecognize,becauseit
constitutesanessentialresourceforpreventingmisunderstandings.
Principle7:communicationentailsfactualandrelation
information
Thisfinalprinciplepostulates thatcommunication alwaysconveys
both factualandrelationalinformation.Intheexamplereferredto
earlierwhereadispatchersaid“Hello.Hello.Youunderstand,you
understand?”, a perceived sense of doubt about the caller’s
competencemaybeaccidentallyconveyednonverballyalongwith
factualCPRinstructions.Non-verbalcommunicationcanbedecoded
inmultipleways,evenifthewordscontainonlyfactualinformation.
Communicationentailsverbalandnonverbalinformationthatcarry
bothinformationalandrelationalmeaning.
Discussion
OurstudyshowedthatDACPRincreasedtheprovisionofbystander
CPRasthecallerswouldnothavestartedifnotinstructedbythe
dispatcher.Basedonourfindings,communicationsafetyduringthe
callcouldbeimprovedwithadditionaltrainingaddressingthequalityof
the (technical)instructions, handlingoverly distraught callersand
languageissues.
Aswithpreviousreports,4,5,8–10DACPRisaneffectivestrategyto
increase the performance of bystander CPR in both adult and
paediatricOHCA.Wefoundthatdispatcher’technicalinstructionson
givingventilationsforpaediatricpatients(asopposedto
compression-onlyCPR)couldbeimproved,takingreferencefromlocalpaediatric
resuscitationguidelines.18Nonetheless,compression-onlyDACPRis
still effective when good quality chest compressions are
per-formed19,20 and this is especially relevant when bystanders are
reluctanttoperformrescuebreaths
PaediatricOHCAisarareevent.Wepostulatethatduetothelow
incidenceofpaediatriccardiacarrests(comparedtoadultarrests),
dispatchersmaytendtoinstructbystanderstodocompression-only
becauseoftheirnaturalfamiliaritywiththeadultDACPRprotocol.
Anotherpossiblereasonfordispatchers notinstructingventilation
maybethedifficultyinprovidingtechnicallydetailedinstructionsfor
ventilation, causing them to deviate from protocol and abandon
InlinewiththepreviousstudyonbarrierstoDACPRinmultilingual
Singapore,14wedidobservesomelanguagebarriers,albeitminimal.
Thiscouldbeduetothefactthatthemajorityofthecallers,parentsor
caregivers of thepaediatric cardiacarrest victims, tended to be
youngerandwerethusmorelikelyabletobefluentinEnglishthenthe
oldergeneralpopulation.
Consistent with previous SACCIA studies, issues related to
sufficiencyincommunicationweremostcommon,buttheamountof
issuesrelatedtoclaritywashigherinourstudy.21–24Thisimpliesthe
needtofocusonthesetwoaspectsofDACPRcommunication.There
isanexistingline-by-linedispatchingscriptinEnglish.Inmultilingual
Singapore, however, the dispatchers will occasionally need to
translatethisscripttotheotherlocallanguages(Mandarin,Tamil,
Malay)andevenintodialects(e.g.,Hokkien,Teochew).Thescripthas
tobalancesimplificationandspecificationasithasbeenshownthat
simplifiedDACPRinstructioncanimproveCPRquality.25–30
Valida-tionstudiesareneededtoexamine,forinstance,whethertheuseof
‘pushashardasyoucan’can achievegreaterdepthandrateof
compression than ‘push approximately 4cm’. Clear and simple
technicalinstructionsarenecessaryasthebystanderwillbeunder
emotionaldistressduringpaediatricOHCA,whichcancompromise
DACPRperformance.31–33
Nonverbalcommunicationcannotbedisregardedinthecontextof
DACPR where callers are often overly distraught. Ninety-three
percentoftheunderstandingofamessageisderivedfromnonverbal
communicationsuchaskinesics(55%)andvocaliccues(38%),with
thespokenwordsconstitutingonly7%ofthemeaning.20Eventhough
kinesicsareunavailableinphonecommunications,vocaliccuessuch
asinflectionofthevoice,rateoftalking,loudness,andexpressivity
contributetowardsasharedunderstandinginDACPR.
WerecommendthatDACPRtrainingfordispatchersshouldfocus
onappropriaterepetition(e.g.,engagingcallerstoactivelycounttheir
compressions out loud). The training could also focus on the
directness of the channel (using multiple functions of the smart
phonetofacilitateDACPRcommunication,e.g.,videocall,34GPS
location,orspecificapp’s35,36)andsituation-specificscriptadherence
(e.g., using computer prompts to emphasize important language
specificdetailsofthescript).Otherrecommendationsincludetheuse
ofsimulation tovalidate thetranslation of theDACPRscriptinto
different languages, and the use of a metronome to guide the
dispatcheroncorrectcompressionrates.Furthermore,dissemination
ofinformationandpubliceducationontheDACPRguidelineinOHCA
maybeusefultoincreasethepopulation’sawarenessoftheguideline
contentandreadinesstoperformDACPRwhentheneedarises.
Limitations
Giventhelowincidenceofpaediatriccardiacarrest,wecarriedouta
retrospectivestudy.Themostsignificantlimitationwastheinabilityto
involvebothdispatcherandcallerforeverycaseinordertounderstand
theirperspectivesaboutinstructionandcommunicationissuesduring
DACPR.Ourobservations werefromathird-person perspective,based
ontheavailableaudio,whichmaynothavetrulyreflectedtheissuesor
theconcernsofthedispatcherandcaller.Thismighthaveimpactedthe
categorizationoftheSACCIA1issuesascommunicationissuesarenot
alwayseasytodistinguishandmayfallundermorethanonecategory.
Furthermore, the exactreasons behind non-complianceto current
DACPR guidelines could not be ascertained as there was no
documentationavailableandinterviewingthedispatcherinvolvedafter
theeventwouldhaveintroducedrecallbias.
Conclusion
AstructuredevaluationofcommunicationissuesusingtheSACCIA1
typology in paediatric DACPR for OHCA allowed identification of specific
communicationissues.Wefoundanaverageof1.9communication
issuespercall.Majorityoftheissueswererelatedtosufficiencyand
accuracyofcommunication.Ourtrainingrecommendationsfocuson
simulated situation andlanguage-specificguidelineapplicationand
movingbeyondverbalcommunicationbyutilizingmorefunctionsofthe
smartphone.Prospectiveeffortsarenecessarytoevaluatewhetherthis
translatesintoimprovedprovisionofpaediatricDACPR.
Acknowledgements
TheauthorsthanktheSCDFControlRoomStafffortheirparticipation
inthisstudy.
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