Study reveals major differences in emergency dispatch of community first responders

Jonas finds his wife lying on the living-room floor. She is gasping for air and struggling to breathe, so he calls 112. While the ambulance is being dispatched, the call handler at the emergency call centre must determine whether this could be a cardiac arrest – and whether nearby CFRs should be alerted so that life-saving first aid can begin before the ambulance arrives.

But at that crucial moment, the community first responder (CFR) system was not always activated. Dispatchers in the Capital Region only alerted CFRs in 57% of the cardiac arrests that met the criteria.

That observation became the starting-point for a study by physician and PhD student Persia Shahriari together with Fredrik Folke, consultant and clinical professor at the Capital Region Emergency Medical Services. The researchers examined the gap between the formal criteria for activating the CFR system and how it is actually used in practice.

“The whole idea behind the community first responder system is that we dispatch responders to suspected cardiac arrests when the criteria are met. That is why I was surprised that the scheme was not used more often. What determined when responders were activated – and when they were not?” says Folke.

Researchers examined the decisions inside the emergency call centre

The idea for the study grew out of a paradox. Many countries have established community first responder systems, but the researchers were unable to find any large studies examining how they are actually used in practice. Most studies focused on the app and the technology – far fewer on the crucial moment inside the emergency call centre, where a cardiac arrest must first be recognised and responders activated.

And this is where the paradox lies, Folke points out: even the best technical solution has limited value if the system is not activated when a cardiac arrest is suspected.

That is why the researchers turned to Denmark’s CFR system, which combines a large nationwide network of volunteers with detailed data on the actual emergency response process.

“That is why we analysed our own data to better understand the situations in which the criteria indicated that community first responders should have been activated,” says Fredrik Folke.

The researchers reviewed all 7,683 suspected out-of-hospital cardiac arrests in the Capital Region of Denmark between September 2017 and December 2023. They then excluded situations in which the rules state that CFRs should not be alerted, such as unsafe environments or nursing homes where healthcare professionals were already present.

That left 4,320 cardiac arrests in which CFRs could potentially be activated. The researchers linked each case to factors including the person’s age and sex, the location of the cardiac arrest and ambulance response time.

“The method allowed us to follow the entire emergency response chain and identify which factors were associated with the decision. That is very different from simply measuring how many people have downloaded an app,” says Folke.

“Even among experienced staff who regularly handle 112 calls involving cardiac arrest, there turned out to be substantial variation in how the system was used,” says Fredrik Folke.

Overall, CFRs were activated in 2,486 of the 4,320 cases in which the criteria indicated that the system should have been activated.

Large differences in how the scheme was used

The researchers then examined which situations most often led to activation of the CFR system. Here, clear patterns began to emerge in the data.

CFRs were more often activated for cardiac arrests in private homes than in public places. In addition, the likelihood of activation increased the further away the nearest ambulance was.

According to Folke, both patterns make good sense in the reality of emergency response work. For example, a dispatcher may decide not to activate the scheme if an ambulance is already close to the address or if bystanders have already started cardiopulmonary resuscitation and a defibrillator is already available on site.

“The findings need to be interpreted with some nuance. The specific circumstances at the location are not visible in the data, but they may influence the assessment made at the emergency call centre. That is why it is neither realistic nor necessarily appropriate to activate community first responders for every cardiac arrest,” says Fredrik Folke.

Nevertheless, the findings pointed to situations in which the scheme could potentially be used more consistently. The research group therefore reviewed the results together with the dispatch staff and discussed both opportunities and barriers to increasing use of the system.

More specifically, the activation button has been made easier to access during the 112 call, and the research team has reviewed the findings together with dispatch staff and discussed when the scheme should be activated.

“These initiatives already appear to be making a difference, because the community first responder system has been activated more frequently in the months since,” says Fredrik Folke.

The study also revealed a more unexpected pattern: women and men with suspected cardiac arrest were not equally likely to have CFRs activated.

Women were less likely to have responders activated

Among people aged 66 to 80 years, the CFR system was activated for 55.3% of women and 62.8% of men. Among people older than 80 years, the difference widened further to 45.5% for women and 59.3% for men.

According to Fredrik Folke, the dispatch staff initially had difficulty recognising this pattern from their own work.

“It came as a real surprise to both us and the healthcare professionals. They certainly do not feel that they discriminate on the basis of sex. That is why we want to investigate this finding further,” says Fredrik Folke.

The researchers believe the explanation may be linked to differences in how cardiac arrest initially presents in women and men. Women are often older than men when they experience cardiac arrest.

In addition, women more often experience shortness of breath rather than classic chest pain before collapsing. As a result, recognising that a cardiac arrest is actually taking place may take longer. And by the time that recognition happens, the ambulance is often already so close that activating CFRs no longer makes sense.

Researchers are now examining the crucial minutes

The researchers are now reviewing recordings of the 112 calls to map what happens during the first minutes of the conversation.

“The hard data show us where the patterns are. But it does not tell us why they arise. The explanation may lie in the communication between the person calling 112 and the person receiving the call. That is why we need to look more closely at the conversation itself,” says Fredrik Folke.

Folke and his colleagues will take a closer look at cardiac arrests in social housing areas in the Capital Region, where survival rates appear to be particularly low.

Here, they will investigate whether aspects of the conversation between the caller and the dispatcher may delay recognition of cardiac arrest – for example language barriers or differences in how symptoms are described.

In principle, it could also involve unconscious bias, in which certain groups are inadvertently overlooked. Although this may be difficult to imagine, investigating this further is important, he says.

The researchers also want to examine how often the emergency call centre actually makes the correct assessment when a suspected cardiac arrest leads to activation of the CFR system.

The findings may help clarify when the emergency call centre gets it right – and where dispatch staff may need better decision support, says Fredrik Folke.

But the biggest question remains unanswered: does the HeartRunner programme actually save lives? The answer may come from the randomised HeartRunner clinical trial, which has enrolled more than 2,000 patients over the past seven years. Recruitment ended on 1 March 2026, and the researchers are now collecting data on 30-day survival.

“The randomised trial will hopefully give us the answer we have so far been unable to obtain. Only then can we say with greater confidence whether the HeartRunner scheme saves lives in the form we use in Denmark,” says Folke.

Other countries are also looking for answers

Because the study is the first of its kind worldwide, Folke and his colleagues hope it will encourage other countries to examine their own systems more systematically. Many countries have established similar schemes without really knowing how they function in practice. Here, the study in Denmark offers a rare glimpse into when the system actually translates into concrete help.

And perhaps it is precisely this international perspective that explains why the journal publishing the study chose to accompany it with an editorial. Two international researchers argue that community first responder systems can only shorten the time to life-saving treatment if they are activated consistently and fairly. Further, they warn that hesitation can become self-reinforcing. Fewer activations lead to fewer interventions, less experience within the responder network and, ultimately, less confidence that the system makes a difference.

For Folke, the international interest suggests that the research group has touched on a question the field has long lacked an answer to.

“It was the first paper Persia Shahriari submitted as first author, and I have never experienced such a positive response. The peer reviewers had many suggestions for revisions, but they recognised from the outset that the study had significance far beyond Denmark,” says Fredrik Folke.