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ORIGINAL RESEARCH Open Access
Misplaced links in the chain of survival due to an
incorrect manual for the emergency call at public
facilities
Yutaka Takei
1
, Taiki Nishi
2
, Keiko Takase
2
, Takahisa Kamikura
2
and Hideo Inaba
3*
Abstract
Background: The incidence of delayed emergency calls and the outcome of out-of-hospital cardiac arrest (OHCA)
may differ among public facilities when emergency calls are placed by institutional staff. The purpose of this study
was to identify the actions prescribed in the rules and/or manuals of public facilities and to clarify whether the
incidence of delayed emergency call placement and the outcome of OHCA differ among these facilities.
Methods: We performed a questionnaire-based survey regarding emergency calls in public facilities in our
community and analyzed our regional Utstein-based OHCA database.
Results: Our questionnaire survey disclosed that the most common actions prescribed in the manuals or rules
applied in care facilities and educational institutions are to report the situation when a cardiac arrest occurs and to
follow the directions of a custodian or supervisor. The international web search disclosed that these actions are
rarely prescribed in medical emergency manuals in other countries. Most of these manuals simply say that staff
should make an emergency call immediately upon detecting a serious illness or medical emergency. Analysis of the
Utstein-based database from our community revealed that the time interval between collapse and emergency call
placement is prolonged and the outcome of cardiac arrest poor in care facilities. A prompt emergency call and
cardiopulmonary resuscitation (CPR) after arrest are associated with improved 1-year survival following OHCA.
Contrary to accepted wisdom, staff who recognize a cardiac arrest may consult their supervisor and then continue
CPR until they receive instructions from him or her.
Conclusions: Manuals or rules for making emergency calls in our public facilities may contain incorrect information,
and emergency calls may be delayed owing to correctable human factors. Such manuals should be checked and
revised.
Keywords: Out-of-hospital cardiac arrest; Emergency call; Public facilities; Questionnaire survey; Prospective cohort
study
Background
Survival after an out-of-hospital cardiac arrest (OHCA)
depends on the following links in the “chain of survival”:
immediate recognition of cardiac arrest and activation of
the emergency response system, early cardiopulmonary
resuscitation (CPR), rapid defibrillation, effective Ad-
vanced Life Support, and integrated post-cardiac arrest
care [1]. Appropriate and prompt attention to these
links, particularly the first three, is essential for survival
after OHCA [2-4].
Accumulating evidence shows that a long delay in pla-
cing an emergency call worsens the outcome of OHCA
[5-7]. Our previous study reported that the delay was
most frequen tly caused by human factors and that long
delays were likely to occur in care facilities [5].
In a public facility, an emergency call may occasionally
be placed by a member of the staff during business
hours. In these cases, though CPR may be initiated early
by bystanders, including trained staff, the emergency call
* Correspondence: hidinaba@med.m.kanazawa-u.ac.jp
3
Departments of Emergency Medical Science and Emergency Medical
Center, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi,
Kanazawa 920-8641, Japan
Full list of author information is available at the end of the article
© 2013 Takei et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly cited.
Takei et al. International Journal of Emergency Medicine 2013, 6:33
http://www.intjem.com/content/6/1/33
may be placed by a staff member according to the insti-
tution’s rules and/or manuals.
We hypothesized that the placement of an emergency
call might be delayed in care facilities owing to human
factors based on an incorrect manual and that a similar
problem or a “CPR-first” policy might exist in other fa-
cilities in which an emergency call may be made by a
staff member or custodian. The purpose of this study
was to identify the actions that are prescribed in the
rules and/or manuals of public facilities and to deter-
mine whether the incidence of delayed emergency call
placement and the outcome of OHCA differ among
these facilities.
Methods
Data were collected in accordance with the national ethics
guidelines for epidemiological surveys (Ministry of Health,
Labor and Welfare in Japan: http://www.mhlw.go.jp/
general/seido/kousei/i-kenkyu/index.html). The study was
approved by an institutional review board (reference no. 923).
Populations and settings
The Ishikawa prefecture of Japan encompasses an area
of 4,185 km
2
and has a resident population of 1,160,000.
The prefecture is divided into four administrative re-
gions comprising one central or urban region and three
semirural or rural regions. Sixty-two percent of the resi-
dents are located in the central (urban) region, which
has an area of 1,432 km
2
. An estimated 22% of the resi-
dents are over the age of 65 years. Population aging is
more pronounced in the rural areas than in the urban
areas (25.5 vs. 20.3% of residents are over 65 years old,
respectively).
There are 11 fire departments and 55 registered ambu-
lances in the Ishikawa prefecture. Each fire department
has a dispatch system with telephone-assisted CPR in-
struction. Emergency medical technicians (EMTs) resus-
citate OHCA patients according to a protocol developed
by the Ishikawa Medical Control Councils based on the
guidelines of the American Heart Association and the
Japan Resuscitation Council, unless the patient has post-
mortem changes. During resuscitation, paramedics are
authorized to perform the following procedures: use of
suprapharyngeal airway devices, infusion of Ringer’s
lactate through a peripheral vein, and the use of a semi-
automated external defibrillator. Since July 2004, spe-
cially trained paramedics have been permitted to insert
tracheal tubes, and since April 2006 they have been per-
mitted to administer intravenous adrenalin. EMTs are
not permitted to terminate resuscitation in the field.
Questionnaire-based survey regarding emergency calls
The authors collected rules and/or manuals applied
when a cardiac arrest or a serious acute illness that
could lead to cardiac arrest occurs. The authors sent a
questionnaire to public facilities where eme rgency calls
may be occasionally placed by staff members. We identi-
fied the care facilities and educational institutions from
Ishikawa prefecture websites. A list of municipal public
halls/community centers was generated from the
homepage of each city. A list of hotels and ryokans
(Japanese traditional lodges) was generated from a book
of Japanese postal service zip codes, and a list of shop-
ping centers was generated using a telephone number
search system. The following types of care facility exist
in Japan: residential care facilities for elderly individuals
who require short-term daily care; communal daily long-
term care for dementia patients; long-term care health
facilities; facilities covered by public aid that provide
long-term care; and sanatoriums for elderly patients who
require long-term care. We excluded residential care fa-
cilities from our survey because their capacity is very
small and because they are open only in the daytime.
We mailed the questionnaire to all of the identified insti-
tutions and obtained from each both their reply to the
questionnaire and a copy of their manual applied when
cardiac arrest and/or serious acute conditions leading to
cardiac arrest occur. The questionnaire is presented in
Table 1.
Web search for medical emergency manuals in other
countries
We conducted a web search using combinations of
following terms: “medical” , “emergency”, “procedures ” ,
“manual”, “nursing”, and /or “public facilities”.
Patient data
Baseline data were prospectively collected for OHCAs
that were witnessed or recognized from April 2003
through March 2009 at public facilities in which emer-
gency calls were occasionally made by the staff in ac-
cordance with a rule or manual.
The public facilities that were analyzed in this study
included various grades of care facility, educational insti-
tutions, other facilities at which citizens assemble (such
as shopping centers, community centers, sports centers,
and recreational facilities), and hotels. The collected data
were based on the Utstein template [8,9] and included
the region; location of the OHCA; patient’s age, gender,
and prior disabilities; any witnes ses to the arrest; the eti-
ology of the arrest; the caller; bystander CPR; the iden-
tity of the individual who performed CPR; the initial
cardiac rhythm; the interval between the recognition of
the arrest or the collapse and the call placement; the
interval between the call placement and the first CPR;
the interval between the call placement and the arrival
of EMTs at the patient; and 1-year survival rate. Patients
were considered to have survived for 1 year if they were
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 2 of 9
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alive in hospital, at home, or in a care and/or rehabilita-
tion facility 1 year after the OHCA. W hen the emer-
gency call was made after the initiation of CPR or when
the interval of the emergency call to the initiation of
bystander CPR (the call-bystander CPR inter val) was
less than 0 min, the reasons for this CPR-first action
were identified by the E M Ts by inter viewing by-
standers. The rea sons were cla ssified into preventable
and unpreventable causes, as described previously [5].
Last, we extracted cases of bystander-witnessed OHCAs
in which bystanders performed CPR on their own initia-
tive and used these data to determine differences in the in-
cidence of delayed emergency calls and the outcome of
OHCA among public facilities. The primary end point
was the survival rate at 1 year. We cleaned all data at least
twice before generating the final database by requesting
the fire departments to fix the inconsistency in the data.
Statistical analysis
We analyzed the data using the Joint Medical Program
version 8 for Windows (Statistical Analysis System Insti-
tute, Cary, NC, USA). Chi-square tests with/without
Pearson’s correction or Fisher exact probability tests
were applied for univariate analyses. The Kruskal-Wallis
test was used for non-parametric comparisons. In all
analyses, differences with p < 0.05 were considered
significant.
Results
Analysis of the questionnaire survey data
The response rate to the questionnaire wa s similar
among the different types of public facility and ranged
from 45% to 58%. Care facilities and educational institu-
tions were most likely to periodically provide basic life
support (BLS) courses (85% and 96%, respectively) and
often had manuals that covered serious medical emer-
gencies (89% and 79%, respectively). Eighty-nine percent
of all care facility staff were healthcare providers. Auto-
mated external defibrillators (AEDs) were installed in
every high school and university (100%), but were much
less common in care facilities (30.1%). Most of the care
facilities (89.2%) had consulted with patients’ family
members regarding the actions to take in the event of a
serious medical emergency. The most common actions
prescribed in a rule or manual to be applied when a car-
diac arrest occurred in a care facility or educational in-
stitution were to report the situation and then to follow
the directions of a supervisor or medical staff member
Table 2.
Web search results
We identified 16 full text manuals from three public in-
stitutes in the US and 5 universities in the US, Canada,
Austria and the UK. Thirteen manuals prescribed “call
first” (81%); “other actions” included contacting a trained
Table 1 Analysis of the questionnaire survey data
Questions Ideal response
Q1. Does your facility have any manual or rule book covering serious medical emergencies in which a person (resident, visitor)
becomes unresponsive or his or her physical condition abruptly deteriorates?
Yes
Answer: “Yes” or “No”
If you answered “Yes” to Q1, please answer Q2 and select one of the items
If you answered “No” to Q1, please answer Q3 and select one of the items
Q2. What is the first action that a staff member is required to take for the medical emergency? Call first
immediately
Q3. How should staff members act in the medical emergency? 1. Call 119 first
1. Call 119 first and then examine the victim in detail
2. First examine the victim in detail and then call 119
3. Report the situation and then follow the instructions of a supervisor or medical staff member
4. Immediately initiate CPR or other treatment for the patient and then call 119 if necessary.
5. Other action (please specify).
Q4. Does a medical doctor or nurse work every day at your facility? Please choose from the following answers: 1. Works every day
1. Works every day
2. Works part of the day
3. Does not work at our facility.
4. Other (please specify).
Q5. Does your facility periodically provide basic life support courses? Yes
Q6. Does your facility have an automated external defibrillator (AED)? Yes
Q7. Does your facility consult family members regarding what actions to take in the event of a serious medical emergency? Yes
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 3 of 9
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first aid officer, reception, facility manager, administra-
tion, or security officer.
Characteristics and outcomes of OHCA patients
As shown in Table 3, female patients, older patients,
prior disabilities, and OHCAs of non-cardiac etiology
were significantly more comm on in care facilities. Both
the interval between arrest recognition/collapse and
placement of the emergency call and the interval be-
tween emergency call placement and the arrival of EMTs
were longer in care facilities. In care facilities, the inci-
dence of CPR before EMT arrival was higher, and CPR
was more frequently initiated before the emergenc y call.
Resuscitation was most frequently attempted by
healthcare providers at the care facilities, and the emer-
gency call was most frequently placed by a staff member
(99%, compared with 86% for educational institutions
and 56% for other institutions, p < 0.0001). Concerning
the incidence of CPR-first cases with a subtractive call –
bystander CPR interval value was 53.9% in care facilities
and 49.2% in other facilities for OHCAs with bystander
CPR. In most of the CPR-first cases (98.8% in care facil-
ities and 60.6% in other facilities), the cause of the de-
layed emergency call was preventable.
The link s in the chain of sur vival for care and other
facilities are illustrated in Figure 1. The median inter-
val between arrest re cognition/collapse and t he emer-
gency c all was 2 min [interquartile range (IQR) = 1–6]
in care facilities and 2 min (IQR = 1–4) in other facil-
ities (p < 0.0001). The median inter val between arrest
recognition/collapse and the initiation of CPR before
EMT arrival was 1 min (IQR = 0–3) in care facilities
and 2 min (IQR = 1–5) in other facilities ( p = 0.0007).
The median inter va l between arrest recognition/
Table 2 Characteristics of public facilities and summary of questionnaire survey
Care
facilities
Other facilities p-value
High schools
and universities
Community
centers
Hotels and
shopping
centers
Responses to the questionnaire, n/mailed number (%) 157/269 (58.4) 47/83 (56.6) 229/487 (47.0) 0.2111
120/245 (49.0) 109/242 (45.0) 0.3373
Manual or rule for serious medical emergencies, n/total
responses (%)
138/155 (89.0) 37/47 (78.7) 56/228 (24.6) <0.0001
11/121 (9.1) 45/107 (42.1) <0.0001
Healthcare provider, n/total responses (%)
Works every day 101/153 (66.0) 19/46 (41.3) 7/225 (3.1) <0.0001
2/120 (1.7) 5/105 (4.8) <0.0001
Works part of the day 35/153 (22.9) 3/46 (6.5) 2/225 (0.9) <0.0001
1/120 (0.8) 1/105 (1.0) <0.0001
None 17/153 (11.1) 24/46 (52.2) 216/225 (96.0) <0.0001
117/120 (97.6) 99/105 (94.3) <0.0001
Provide Basic Life Support course periodically, n/total responses (%) 129/152 (84.9) 44/46 (95.7) 107/224 (47.8) <0.0001
64/119 (53.8) 43/105 (41.0) <0.0001
Automated external defibrillator (AED) installed, n/total
responses (%)
46/153 (30.1) 46/46 (100) 91/225 (40.4) 0.0394
48/120 (40.0) 43/105 (41.0) <0.0001
Consult family members regarding what actions to take in the
event of a serious medical emergency, n/total responses (%)
132/148 (89.2) –––
Actions prescribed in a manual and applied when cardiac arrest
occurs (%)
Call 119 first and then check the victim in detail 43/155 (27.7) 17/45 (37.8) 170/227 (74.9) <0.0001
96/120 (80.0) 74/107 (69.2) <0.0001
Call 119 after checking the victim in detail 14/155 (9.0) 7/45 (15.6) 27/227 (7.1) <0.0001
14/120 (11.7) 13/107 (12.1) <0.0001
Report the situation and follow instructions from a supervisor or
medical staff
86/155 (55.5) 16/45 (35.6) 12/227 (5.3) <0.0001
3/120 (2.5) 9/107 (8.4) <0.0001
Start CPR or other treatment immediately and call 119 if necessary 12/155 (7.7) 5/45 (11.1) 18/227 (7.9) <0.0001
7/120 (5.8) 11/107 (10.3) <0.0001
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 4 of 9
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collapse and the initiation of resuscitation by EMTs was 8
min (IQR = 6–11) in care facilities and 7 min (IQR = 5–9)
in other facilities (p < 0.0001). The median interval be-
tween arrest recognition/collapse and defibrillation was 18
min (IQR = 12–26) in care facilities and 12 min (IQR =
9–18) in other facilities (p = 0.0336). As shown Figure 2,
the incidence of ventricular fibrillation/ventricular tachy-
cardia as the initial rhythm and survival rates at 1 month
and 1 year were significantly lower in care facilities.
Survival at 1 year in six groups of bystander-witnessed
OHCAs with bystander-initiated CPR
We extracted 192 cases of bystander-witnessed OHCAs
in which bystanders performed CPR on their own initia-
tive. The median collapse-call and call-CPR intervals
were 2 min (IQR = 1–5) and 1 min (IQR = 0–3), re-
spectively. We classified the 192 cases into six groups
according to the collapse-call and call-CPR interval. As
shown in Table 4, there were no survivors at 1 year
Table 3 Differences between care facilities and other facilities in characteristics of OHCA patients
Care
facilities
High schools and
universities
Others p-value Odds ratio (95% CI)
(n = 556) (n =8) (n = 386)
Other public facilities
(n = 394)
Region 262 (47.1) 7 (87.5) 192 (49.7) 0.4290* 0.900 (0.694–1.168)*
Central or urban (%) 199 (50.5) 0.3037 0.873 (0.674–1.131)
Patient’s gender 197 (35.4) 6 (75.0) 299 (77.5) <0.0001* 0.160 (0.119–0.215)*
Male (%) 305 (77.4) <0.0001 0.160 (0.119–0.215)
Patient’s age, years, median (25–75%) 86 (81–91) 17 (16–64) 68 (56–78) <0.0001* Undefined
68 (55–78) <0.0001 Undefined
Patient’s prior disabilities 137 (24.6) 8 (100) 318 (82.4) <0.0001* 0.070 (0.051–0.097)*
None (%) 326 (82.7) <0.0001 0.068 (0.049–0.094)
Etiology 280 (50.4) 3 (37.5) 222 (57.5) 0.0303* 0.749 (0.577–0.973)*
Cardiac (%) 225 (57.1) 0.0399 0.762 (0.588–0.988)
Arrest 324 (58.3) 2 (25.0) 217 (55.1) 0.5304* 1.088 (0.837–1.414)*
Witnessed (%) 219 (55.6) 0.4093 1.116 (0.860–1.448)
Interval from arrest recognition/collapse to call, min,
median (10-25-75-90%)
2 2.5 2 0.0006* Undefined
(0-1-7-9) (0-1-4-8)
(−1-1-6-13) 2 (0-1-4-8) 0.0007 Undefined
CPR before EMT arrival (%) 455 (81.8) 5 (62.5) 182 (47.2) <0.0001* 5.050 (3.763–6.775)*
187 (47.5) <0.0001 4.987 (3.712–6.681)
CPR performer 339/455 (74.5) 0/5 (0) 33/182
(18.1)
<0.0001* 12.719 (8.293–19.505)
*
Healthcare provider, n/total BCPR (%) 33/193 (17.1) <0.0001 13.208 (8.622–20.234)
CPR first, n/total BCPR (%) 245/455 (53.9) 3/5 (60.0) 89/182
(48.9)
0.4994 1.219 (0.864–1.720)*
92/187 (49.2) 0.2839 1.205 (0.857
–1.694)
CPR first for preventable reason, n/total CPR first (%) 80/81 (98.8) 0/2 (0) 20/31
(64.5)
<0.0001 44 (5.362–361.091)*
20/33 (60.6) <0.0001 52 (6.418–421.316)
Interval from call to arrival of EMT at patient, min, median
(25–75%)
8(6–11) 5 (5–6.5) 7 (5–9) <0.0001* Undefined
7(5–9) <0.0001 Undefined
Emergency call placed by institution staff, n/total (%) 538/542 (99.3) 6/7 (85.7) 91/164
(55.5%)
<0.0001* 107.9 (38.5–302.4)*
97/171 (56.7) <0.0001 102.6 (36.7–287.2)
CI confidence interval, CPR cardiopulmonary resuscitation, EMT emergency medical technician, BCPR bystander cardiopulmonary resuscitation.
*Comparison between care facilities and other facilities excluding schools.
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 5 of 9
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Figure 1 Placements of links in the "chain of survival" for care facilities and other facilities. The widths of circles represent an interquartile
range (25-75%). The heights of circles denote the incidence. CPR cardiopulmonary resuscitation, EMT emergency medical technician, BLS basic life
support, ACLS advanced cardiovascular life support.
0%
5%
10%
15%
20%
25%
30%
Shockable rhythm* SROSC 1month survival* 1 year survival*
All OHCAs
21/556
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Shockable rhythm* SROSC 1month survival* 1 year survival*
Bystander witnessed OHCAs of cardiac etiology
Care facilities Other
p
ublic facilities
p
<0.00 1
p
=0.074
p
<0.00 1
p
<0.0 01
p
<0.0 01
p
=0. 809
p
=0.0 08
p
=0.00 3
71/394
140/556
122/394
127/556
112/394
12/556 32/394
11/109
49/107
36/109
37/107
6/109
18/107
3/109
15/107
Figure 2 Comparison of the outcome and incidence of VF/VT in relation to location. SROSC sustained return of spontaneous circulation.
*Significantly different between care facilities and other public facilities (p < 0.05).
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 6 of 9
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when the emergency call was considerably delayed (col-
lapse-call interval ≥6 min). When the emergency call was
not considerably delayed (collapse-call interval <6 min),
survival at 1 year was greatest in cases without a long
delay in CPR (cases with a call-CPR interval <3 min). The
1-year survival rate appeared to be lower in 54 CPR-first
cases (call-CPR interval <0 min) than in 94 cases in which
CPR was undertaken in the standard order (call first: call-
CPR interval = 0–3 min). However, this difference was not
statistically significant (p =0.487,Fisher’s exact probability
test).
Discussion
Our questionnaire survey disclosed that emergency
manuals for serious injury and illness in Japanese public
facilities frequently give priority to reporting the incident
to a custodian or supervisor rather than to making an
immediate emergency call or notifying emergency
medical services (EMSs). Incorrect manuals are most
frequently found in care facilities and educational insti-
tutes. The incidence of emergency calls made after in-
structions from a custodian or supervisor was high in
facilities where the call was placed by a member of staff;
it was highest in care facilities and lowest in public facil-
ities other than educational institutions. Staff who wit-
ness or recognize a cardiac arrest may consult their
supervisor first and then perform CPR until they receive
instructions from him or her. This delay before an emer-
gency call is made is presumably related to the low sur-
vival rate of OHCAs in care facilities.
Japanese care facilities are multifarious. Many elderly
people with minor disabilities live in facilities for daily
life care, owing to the aging population and the increas-
ing number of nuclear families comprising entirely aged
members [10]. In care facilities providing medical care,
members of the family of patients with serious disabil-
ities are consulted regarding the actions to take in the
event of a medical emergency. Not all patients who suf-
fer a cardiac arrest in these facilities are transported by
the EMSs. We found that BLS courses were periodically
held in most of the care facilities and resuscitation was
started early. Nevertheless, the outcome of cardiac arrest
at care facilities was poor.
Our questionnaire-based survey revealed differences in
AED availability among public facilities. Care facilities
were the least likely to have an AED installed (30%), and
high schools and universities were most likely (100%).
This suggests that the delay of emergency calls in care
facilities might be associated with a delay of AED use by
EMTs and the low incidence of shockable initial rhythm.
Our web search disclosed that most manuals in col-
leges in other countries prescribed call-first actions
[11-14]. The manuals state simply that staff should make
an emergency call immediately after they encounter a
serious illness or medical emergency. However, we failed
to find any manuals applied in care facilities in our web
search. A further questionnaire survey may be necessary
to determine whether incorrect manuals are present in
care facilities internationally.
Incorrect manuals that upset the order of the links in
the chain of survival were present not only in care facil-
ities but also in schools. However, we were unable to
perform a precise comparison of the backgrounds and
outcomes of OHC As between educational and other fa-
cilities because the number of OHCAs that occurred at
educational facilities was low. Further investigation will
be necessary to determine BLS actions at schools and
universities.
Previous studies in the US have reported that OHCA
patients in care facilities are frequently elderly males
with a disability or illness and that the incidence of
witnessed cardiac arrest ranges from 38% to 49% [15,16].
It has also been reported that the inc idence of bystander
CPR is higher in care facilities than in other public facil-
ities [17]. The characteristics and backgrounds of the
OHCAs in the present study are consist ent with those in
previous reports. Although the quality of bystander CPR
was not determined in our study, periodic BLS courses
were held in most of the care facilities. The quality of
bystander CPR has been reported to be high in locations
where cardiac arrests occur frequently [18]. Our study
showed that bystander CPR in care facilities is predom-
inantly performed by a trained staff member. The emer-
gency call was most frequently placed by a staff member,
and the interval between arrest recognition and place-
ment of the emergency call was significantly prolonged
Table 4 Survival at 1 year in six groups of bystander-witnessed OHCAs where bystanders performed CPR on their own
initiative
Category Interval from
call to
bystander CPR
Considerable delay of emergency call
No YesCall first or CPR first
(interval from collapse to call <6 min) (interval from collapse to call ≥6 min)
Call first with considerable delay of CPR >3 min, n/total 0/5 (0%) 0/20 (0%)
Standard call first with small delay of CPR 0–3 min, n/total 7/94 (6.6%) 0/10 (0%)
CPR first <0 min, n/total 2/54 (1.9%) 0/9 (0%)
Difference in 1-year survival between standard call first and CPR first groups (shadowed boxes) was not statistically significant (p = 0.487, Fisher’s exact
probability test).
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in care facilities compared with other public facilities. A
delay in this critical interval in care facilities has not
been reported in communities othe r than ours.
In agreement with previous reports [19,20], this study
showed that there is a high incidence of non-shockable
initial rhythm and a low sur vival rate among OHCAs in
care facilities. Shah et al. proposed that a low incidence
of witnesses to OHCA and a high incidence of pre-
existing complications are the main reasons for this low
survival rate [16]. In the present study, univariate ana-
lysis revealed that the incidence of prior disability was
higher in care facilities than in other public facilities.
The likelihood of a return of spontaneous circulation
and survival after an OHCA de creases with age [21,22],
and we found the age of OHCA patients to be much
higher in care facilities. Previous studies have reported
incidences of witnessed OHC As of 38–44% [16,23]. In
our region, the incidence of witnessed OHCAs at care
facilities (58.3%) was as high as that at other public facil-
ities (55.6%). The low survival rate of OHCAs in care fa-
cilities may therefore be attributed to a combination of
multiple factors that are related to the setting , including
delays in placing emergency calls.
Limitations
The response rate to our questionnaire-based survey
was lower than we had expected, the prospective cohort
study and the questionnaire survey were not linked, and
the results of the questionnaire did not necessarily re-
flect the circumstances at the public facilities that were
analyzed in the prospective cohort study. However, it is
clear that intervention, including educatio n of facility
staff and revision of manuals, is necessary to resolve this
common issue in public institutions, particularly care fa-
cilities, high schools, and universities.
Conclusions
Our questionnaire-based sur vey showed that emergency
manuals for dealing with serious injury or illness in Japa-
nese public facilities give priority to reporting the inci-
dent to a custodian or supervisor rather than to making
an immediate emergency call or notifying EMSs. Such
incorrect manuals are common in care facilities and
educational institutes, and emergency manuals in all
public facilities should be checked and revised.
Abbreviations
OHCA: Out-of-hospital cardiac arrest; CPR: Cardiopulmonary resuscitation;
BLS: Basic life support; EMT: Emergency medical technicians;
SROSC: Sustained return of spontaneous circulation; AED: Automated
external defibrillator.
Competing interests
The authors state that we have no competing interests.
Authors’ contributions
YT was coordinated the manuscript submissions. He conducted background
research, performed data analysis, and drafted the manuscript. TN helped to
design the survey and assisted with data analysis. He contributed
substantially to the manuscript revision. KT and TK assisted with data
analysis. HI was the country coordinator who oversaw data collection. He
contributed substantially to data interpretation and to the manuscript
writing. HI takes responsibility for the paper as a whole. All authors read and
approved the final manuscript.
Acknowledgements
We would like to thank to all of the fire departments in Ishikawa Medical
Control Council for help in data collection.
Author details
1
Department of Medical Science and Technology, Hiroshima International
University, 555-36 Kurose-gakuendai, Higashi-hiroshima-shi, Hiroshima
739-2695, Japan.
2
Department of Emergency Medical Science, Kanazawa
University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa
920-8641, Japan.
3
Departments of Emergency Medical Science and
Emergency Medical Center, Kanazawa University Graduate School of
Medicine, 13-1 Takara-machi, Kanazawa 920-8641, Japan.
Received: 31 October 2012 Accepted: 12 August 2013
Published: 4 September 2013
References
1. Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al: Part 4:
CPR overview: 2010 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation 2010, 122(18 Suppl 3):S676–S684.
2. HollenbergJ,HerlitzJ,LindqvistJ,RivaG,BohmK,RosenqvistM,et al:
Improved survival after out-of-hospital cardiac arrest is associated
with an increase in p ropor tion of emergency crew-wi tnessed cases
and bystander cardiopulmonary res uscitati on. Circulation 2008,
118:389–396.
3. Garza AG, G ratton MC, Salomone JA , L indholm D, McElro y J , et al:
Improved patient survival using a modified resuscitation protocol
for out-of-hospital cardiac arrest. Circulation 2009,
119:2597–2605.
4. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Ontario
Prehospital Advanced Life Support Study Group, et al: Advanced cardiac
life support in out-of-hospital cardiac arrest. N Engl J Med 2004,
351:647–656.
5. Takei Y, Inaba H, Yachida T, Enami M, Goto Y, Ohta K: Analysis of reasons
for emergency call delays in Japan in relation to location: high incidence
of correctable causes and the impact of delays on patient outcomes.
Resuscitation 2010, 81:1492–1498.
6. Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S: A
short delay from out of hospital cardiac arrest to call for ambulance
increases survival. Eur Heart J 2003, 24:1750–1755.
7. Swor RA, Compton S, Domeier R, et al: Delay prior to calling 9-1-1 is
associated with increased mortality after out-of-hospital cardiac arrest.
Prehosp Emerg Care 2008, 12:333–338.
8. Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L,
et al : Recommended guidelines for uniform reporting of data from out-
of-hospital cardiac arrest: the Utstein style. A statement for health
professionals from a task force of the American Heart Association, the
European Resuscitation Council, the Heart and Stroke Foundation of
Canada, and the Australian Resuscitation Council. Circulation 1991,
84:960–975.
9. Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, International Liason
Committee on Resusitation, et al: Cardiac arrest and cardiopulmonary
resuscitation outcome reports: update and simplification of the Utstein
templates for resuscitation registries. A statement for healthcare
professionals from a task force of the international liaison committee on
resuscitation (American Heart Association, European Resuscitation
Council, Australian Resuscitation Council, New Zealand Resuscitation
Council, Heart and Stroke Foundation of Canada, InterAmerican Heart
Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004,
63:233–
249.
Takei et al. International Journal of Emergency Medicine 2013, 6:33 Page 8 of 9
http://www.intjem.com/content/6/1/33
10. Ribbe MW, Ljunggren G, Steel K, Topinková E, Hawes C, Ikegami N, et al:
Nursing homes in 10 nations: a comparison between countries and
settings. Age Ageing 1997, 26(Suppl 2):3–12.
11. United States: The University of Iowa. http://www.facilities.uiowa.edu/
FMServicesGuide.pdf. Accessed [5 Feb 2012].
12. United States: The University of Texas at Austin. http://www.utexas.edu/
student/housing/pdfs/MaintenanceEmergencyProceduresManualApartments5-
01.pdf. Accessed [5 Feb 2012].
13. Fairfax County Public Schools: United States, http://www.fcps.edu/fts/
safety-security/publications/cmw.pdf. Accessed [5 Sep 2013].
14. United States: Orange County Public Schools. https://www.ocps.net/Parents/
Documents/EmergencyManualDoc.pdf. Accessed [5 Feb 2012].
15. Tresch DD, Neahring JM, Duthie EH, Mark DH, Kartes SK, Aufderheide TP:
Outcomes of cardiopulmonary resuscitation in nursing homes: can we
predict who will benefit? Am J Med 1993, 95:123–130.
16. Shah MN, Fairbanks RJ, Lerner EB: Cardiac arrests in skilled nursing
facilities: continuing room for improvement? J Am Med Dir Assoc 2006,
7:350–354.
17. Vadeboncoeur T, Bobrow BJ, Clark L, Kern KB, Sanders AB, Berg RA, et al:
The save hearts in Arizona registry and education (SHARE) program:
who is performing CPR and where are they doing it? Resuscitation 2007,
75:68–75.
18. Wik L, Steen PA, Bircher NG: Quality of bystander cardiopulmonary
resuscitation influences outcome after prehospital cardiac arrest.
Resuscitation 1994, 28:195–203.
19. Portner ME, Pollack ML, Schirk SK, Schlenker MK: Out of hospital cardiac
arrest locations in a rural community where should we place AEDs?
Prehosp Disaster Med 2004, 19:352–355.
20. Benkendorf R, Swor RA, Jackson R, Rivera EJ, Demrick A: Outcomes of
cardiac arrest in the nursing home: destiny or futility? Prehosp Emerg Care
1997, 1:68–72.
21. Ghusn HF, Teasdale TA, Pepe PE, Ginger VF: Older nursing home residents
have a cardiac arrest survival rate similar to that of older persons living
in the community. J Am Geriatr Soc 1995, 43:520–527.
22. Swor RA, Jackson RE, Tintinalli JE, Pirrallo RG: Does advanced age matter in
outcomes after out-of-hospital cardiac arrest in community-dwelling
adults? Acad Emerg Med 2000, 7:762–768.
23. Ghusn HF, Teasdale TA, Skelly JR: Limiting treatment in nursing home:
knowledge and attitudes of nursing home medical directors. J Am Geriatr
Soc 1995, 43(10):1131–1134.
doi:10.1186/1865-1380-6-33
Cite this article as: Takei et al.: Misplaced links in the chain of survival
due to an incorrect manual for the emergency call at public facilities.
International Journal of Emergency Medicine 2013 6:33.
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