Citizen responders do more than running to save people’s lives

Disease and treatment 3. nov 2021 5 min PhD, Senior Consultant Fredrik Folke Written by Josefine Topsøe

In Denmark, people can sign up for the Heartrunner citizen responder programme, volunteering to be available to carry out cardiopulmonary resuscitation (CPR) by running to a location where a person has a cardiac arrest. New studies shed light on several aspects of the Heartrunner programme, including how it affects the volunteers and the interaction with the healthcare professionals. Overall, the results indicate that the programme benefits everyone, but research is being used to adjust, change and optimise the Heartrunner programme on an ongoing basis to benefit everyone who has a cardiac arrest – as well as the many volunteer responders.

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Every year, more than 700,000 people in Europe and North America have an out-of-hospital cardiac arrest, with 5,000 of these in Denmark. This is a major health problem, but the low survival rate of about 10% can be increased to 50% if the person having a cardiac arrest receives defibrillation with an automated external defibrillator (AED) within minutes. Although Denmark has a rapid ambulance response time of 6–10 minutes nationwide, every single minute is critical for the chance of successful resuscitation, since survival declines by about 10 percentage points per minute elapsing from collapse to first defibrillation.

“I cannot think of other situations in which survival depends so strongly on time. Although ambulances respond rapidly in Denmark, the chance of survival may have dropped by 60–90% if nothing is done before the ambulance arrives,” explains Fredrik Folke, PhD, Senior Consultant at Herlev & Gentofte University Hospital, Clinical Professor and Research Leader at the Copenhagen Emergency Medical Services, Capital Region of Denmark.

Fredrik Folke and colleagues have published several scientific articles on the Heartrunner programme, and their latest studies examined how participating in CPR affects citizen responder volunteers psychologically and the dynamics between the volunteers and the professional emergency medical services.

Running to the right location

The TrygFonden Heartrunner programme was launched in the Capital Region of Denmark in September 2017 by the Copenhagen Emergency Medical Services and TrygFonden, and was rolled out nationwide in 2020. The programme is a huge success, since well over 100,000 volunteers have signed up, being ready to drop everything and run to help others. The Heartrunner programme therefore helps to increase the proportion of the population who can intervene as soon as possible to give CPR and be ready to use the nearest AED.

“By activating citizen responders who happen to be near someone who has a cardiac arrest, we hope to save precious minutes between someone collapsing and starting CPR and defibrillation from an AED. The whole rationale for having many Heartrunners engaged is to improve early CPR and bring an AED to the location of the cardiac arrest as rapidly as possible. Saving a few minutes increases the probability of survival by about 20–60% for a person having a cardiac arrest,” says Fredrik Folke.

Fredrik Folke and his fellow researchers found that a Heartrunner reached the person with a heart attack before the ambulance in 40% of the cases in the Capital Region of Denmark during the first year of the Heartrunner programme. In addition, they also found that defibrillation with a nearby AED was three times more frequent when a Heartrunner arrived before the ambulance than if a Heartrunner was not present.

The unique interaction of volunteers stepping in when the problem is most acute and the deployment of many AEDs in public spaces that are connected to the emergency medical dispatch centres is crucial to saving lives.

Denmark used to be among the least-prepared countries for out-of-hospital cardiac arrests a few decades ago but is now a leader in rapid response and successful resuscitation, and emergency services abroad now use the Heartrunner programme as a benchmark and have copied the measures taken within resuscitation in Denmark.

Psychological effects on Heartrunner volunteers

Good evidence and lots of studies show that bystander CPR and early defibrillation from an AED strongly increase cardiac arrest survival, so Fredrik Folke and colleagues have now examined how the volunteer Heartrunners experience participating in a resuscitation attempt and how the professional ambulance crews and the emergency physicians experience the interaction with the Heartrunners in real cardiac arrest cases.

One side-effect of the Heartrunner programme may be how it affects ordinary citizen responders. About 75% of those registered are not healthcare professionals, since anyone can sign up for the programme.

“Running to help a person having a cardiac arrest can be very mentally demanding. Heartrunners know that people having a cardiac arrest are not likely to survive even if the Heartrunner does everything right. The situation may also be chaotic, with traumatised relatives, and Heartrunners may not have received special training for dealing with this,” explains Fredrik Folke.

Nevertheless, many people still join the programme. The new study therefore examined how Heartrunners respond mentally to an emergency and whether there are physical risks associated with responding to an alarm. All Heartrunners receive a short questionnaire after an alarm through their Heartrunner app, including questions of psychological impact and risk of physical injury.

“In our study of psychological impact, we found that 70% did not experience the resuscitation attempt as mentally stressful, and only 1% reported a very traumatic experience. We contacted these Heartrunners by phone to determine whether they needed help or professional debriefing. Based on these figures, we consider that dispatching people as Heartrunners is responsible. However, we must naturally consider and follow up on the 1% reporting the alarm as traumatic,” says Fredrik Folke, adding:

“We are also investigating the safety associated with running to a person with a cardiac arrest: for example, whether a Heartrunner or others were at risk of getting injured on the way to the emergency site. Only 0.3% reported that they thought they were at risk of getting injured, and the only major injury reported was a broken ankle – telling us that alerting these volunteer responders seems acceptable according to risk of physical injury.”

How the professional emergency services experience the interaction with Heartrunners

The implementation of the Heartrunner programme in Denmark means that ambulance crews and emergency physicians encounter a completely different situation in cardiac arrest resuscitation, which is why the latest Heartrunner research examines the interaction between the Heartrunners and the professional emergency medical services.

“The professional emergency services were previously accustomed to meeting either a random person or relatives who had started CPR, but now they often meet several volunteer Heartrunners who are administering CPR and may also have used a defibrillator,” explains Fredrik Folke.

Since about 75% of all cardiac arrests occur in people’s homes, the researchers investigated whether the emergency services experience problems associated with not being able to immediately differentiate between the Heartrunners and the relatives when they arrive at the home at which someone is being resuscitated.

“Based on a questionnaire and conversations with all the emergency physicians in the Capital Region, we found that 90% perceived the collaboration as relevant and 85% think that the citizen responders performed CPR at a high standard. We are naturally pleased to hear this. In addition, we found that many of the emergency physicians benefitted from the extra assistance provided by the Heartrunners in other important roles such as looking after the relatives, creating good working conditions or carrying equipment,” says Fredrik Folke.

However, Fredrik Folke noted that 20% of the emergency physicians said that they experienced challenges in determining who the relatives were, who the Heartrunners were, and with whom they should communicate.

“We are constantly looking at how we can improve the programme, and I think that all our results are really important for understanding the dynamics. Having a system that enables us to carry out research, observe, analyse data and see the effects on outcomes means that we can constantly change and optimise the Heartrunner programme,” explains Fredrik Folke.

New innovative ways of deploying defibrillators

New, innovative ways to deploy defibrillators are also being investigated, including using drones for rapid delivery of defibrillators: “Drones are smart since they can take off in a few seconds, can carry a defibrillator, and can fly directly to the location of the person having a cardiac arrest and deliver the equipment very close to this person,” concludes Fredrik Folke.

Combining activation of local Heartrunners with a drone delivering the AED at the location of the cardiac arrest might be crucial for successful resuscitation in rural areas with long ambulance response times and a low density of available AEDs.

Immediate psychological impact on citizen responders dispatched through a mobile application to out-of-hospital cardiac arrests” has been published in Resuscitation Plus. “Collaboration between emergency physicians and citizen responders in out-of-hospital cardiac arrest resuscitation” has been published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. In 2019, the Novo Nordisk Foundation awarded a Borregaard Clinical Ascending Grant to Fredrik Folke for the project Improving Out-of-hospital Cardiac Arrest Survival – a Novel and Multifaceted Approach. The project includes research on the optimal placement of automated external defibrillators, using artificial intelligence to recognise emergency calls on suspected cardiac arrest, and developing and optimising the deployment of defibrillators in Denmark, including using drones for delivering AEDs in selected rural areas.

My main research areas are within out-of-hospital cardiac arrest (OHCA) and resuscitation. I have done several studies on use of automated external de...

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