Improved recognition of cardiac arrest after training of EMCC operators

Agonal respiration was the main reason emergency medicine communication center (EMCC) operators in Norway did not recognize cardiac arrest, according to Camilla Hardeland‘s PhD research. However, recognition improved following a targeted intervention.


  1. Instructions of cardiopulmonary resuscitation from an EMCC in Norway resulted in faster and more frequent bystander CPR than instructions from an American EMCC using a different system.
  2. 78 %–94 % of all out-of-hospital cardiac arrests were recognized as such at three Norwegian EMCCs. Agonal breathing was the main barrier.
  3. Targeted simulation, education and feedback significantly improved EMCC recognition of agonal breathing and out-of-hospital cardiac arrest, and reduced time to chest compression.


Thesis: When time counts: Emergency medical dispatch. Exploring, understanding and addressing issues that impact upon timely and adequate allocation of prehospital medical assistance and resources to cardiac arrest patients
Candidate: Camilla Hardeland
Time: September 8, 2017 at 13:15
Place: Oslo University Hospital, Ullevål: Red auditorium, Building 25
Link to university website (in Norwegian)


(1) 77 % of 140 included cardiac arrest calls were recognized as cardiac arrest at the EMCC of Oslo and Nordre Follo. There was no difference in the recognition of cardiac arrest when compared to an EMCC in Richmond, US, using a different dispatch tool.

Furthermore, the same amount of callers to the two EMCCs recieved instructions of cardiopulmonary resuscitation before the ambulance arrived. However, pre-arrival instructions lead to chest compressions more frequently in Norway, and time to chest compression delivery was shorter than in Richmond. Both systems dispatched ambulances efficiently, although 18 seconds faster in Richmond.

(2) The recognition of out-of-hospital cardiac arrest at the EMCCs in Oslo-Akershus, Vestfold-Telemark and Østfold was 89 %, 94 % and 78 %, respectively. The main reason for delayed or failed recognition was agonal breathing, an abnormal pattern of breathing that heralds death. The analyses included 579 cardiac arrest calls.

(3) Following targeted simulation training, education focusing on agonal breathing, structured dispatcher feedback and web-based telephone assisted CPR training, the recognition of out-of-hospital cardiac arrest increased to 95 % in Oslo-Akershus.

A total of 561 emergency calls were included in this study. Misinterpretation of agonal breathing decreased, chest compression instructions were provided earlier, and time to initiation of telephone assisted chest compressions were reduced following the intervention.


(1) Hardeland, C., Olasveengen, T. M., Lawrence, R., Garrison, D., Lorem, T., Farstad, G., & Wik, L. (2014). Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest callsResuscitation85(5), 612-616.

(2) Hardeland, C., Sunde, K., Ramsdal, H., Hebbert, S. R., Soilammi, L., Westmark, F., Nordum, F., Hansen, A. E., Steen-Hansen, J. E., & Olasveengen, T. M. (2016). Factors impacting upon timely and adequate allocation of prehospital medical assistance and resources to cardiac arrest patientsResuscitation109, 56-63.

(3) Hardeland, C., Skåre, C., Kramer-Johansen, J., Birkenes, T. S., Myklebust, H., Hansen, A. E., Sunde, K., & Olasveengen, T. M. (2017). Targeted simulation and education to improve cardiac arrest recognition and telephone assisted CPR in an emergency medical communication centreResuscitation114, 21-26.