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New research finds that a Los Angeles program to coach 911 callers through providing CPR improved care in cases where the caller had only limited English proficiency.

The study, published this month in JAMA Network Open, looked at the difference in outcomes for telecommunicator-assisted CPR before and after the Los Angeles Fire Department rolled out a new emergency dispatch system that streamlined the questions asked of a 911 caller. The results suggest a community-specific system like the one Los Angeles developed could better address the needs of culturally underserved populations, and also point to a need for more research on the challenges people with limited English proficiency face in accessing emergency care.

“Cardiac arrest [is] the archetypal 911 emergency — one where bystander activation, bystander response, is absolutely critical,” said Stephen Sanko, an assistant professor of emergency medicine at University of Southern California and an author of the new study.

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There’s a large body of evidence to show that it can be beneficial to coach bystanders over the phone to provide CPR until help arrives. But past research has suggested that only 30% of people who go into cardiac arrest receive CPR from a bystander, and just 13% of patients who are Black or Latino receive CPR from a bystander.

The new program implemented in Los Angeles, called the Los Angeles Tiered Dispatch System or LA-TDS, has already been shown to cut down on the time it takes to process 911 calls and increase the use of bystander CPR for cases of cardiac arrest. The new study set out to see whether LA-TDS increased the use of CPR among callers with limited English proficiency compared to the Medical Priority Dispatch System (MPDS), the system Los Angeles had used for decades and which is used nationwide.

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The research team collected cardiac arrest data from the city of Los Angeles 911 dispatch center over two separate three-month periods — at the start of 2014 for the old system, and at the start of 2015 for the new one — and trained reviewers then analyzed each 911 audio recording that met the study criteria to determine if the caller had limited English proficiency.

To compare the performance of both emergency systems, they looked at how often patients received CPR from a caller with limited English proficiency and the total number of callers with limited English proficiency in which the patient they were calling about was ultimately diagnosed in the field with cardiac arrest. The researchers found the LA-TDS system was over 10% more effective at helping callers with English proficiency and over 40% more effective for patients with limited English proficiency than MPDS at helping callers with limited English proficiency administer CPR.

“Every single step in activating care for a patient plays a crucial role in their ‘neuro intact’ survival, and you’re only as strong as your weakest link,” said Sanko. “If just making that 911 call is the weakest link or if starting CPR, even without training but by following telecommunicated instructions, can be leveraged in order to improve the strength of those early links, then instead of just teaching bystander CPR to the masses, maybe we need a more nuanced approach in some of our communities.”

In the study, only 26 of 289 callers under MPDS and 35 of 308 under LA-TDS were flagged as having limited English proficiency. Despite the small sample sizes, Thomas Rea, the program medical director at King County Medic One Emergency Medical Services, doesn’t believe the importance of the results are undermined.

“I think you can sort of expect that if there is an emergency, among the people in the household, if one of them speaks English and the other two don’t, the natural tendency is going to be for the person who speaks English to make that phone call,” said Rea, who was not involved in the research but co-authored a commentary on the new research. He added that it would be useful to examine other factors that could explain why less people with limited English than expected are utilizing emergency dispatch services.

The improvements seen with LA-TDS point toward a need for community-specific emergency dispatch systems that are able to account for the specific ways social determinants of health operate in a given community, Sanko said, adding that the system “leverages the experience of many of our call takers and medical directors who know our specific community inside and out.”

“Using a new set of questions and new techniques at a dispatch level can help us to markedly improve rates of CPR that, previously, we could not move for years and years,” he said.

Rea agreed that there’s a benefit to having a dispatch team that knows the community well, given the critical role that a 911 system plays in identifying when someone needs CPR and coaching a bystander to start it.

“Life and death in cardiac arrest is usually determined in the outside-hospital environment. The patient’s prognosis and outcome is determined by what happens before they ever reach the hospital,” said Rea. “That’s a humbling reality — the people that are most important to a person’s outcome are the people that are perhaps least trained. It’s the bystander, the laypeople.”

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