Telemedicine in cardiac arrest protocols: Comparative impact of video and audio dispatcher assistance

Abstract

BACKGROUND

In recent years, the utilization of telemedicine in emergency situations, particularly in the context of cardiac arrest, has garnered increasing attention. This study addresses the comparative effectiveness of video-instructed dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) vs audio-instructed DA-CPR, offering valuable insights into the evolving landscape of emergency medical guidance through telecommunication methods.

AIM

To compare the effectiveness of video-instructed DA-CPR and audio-instructed DA-CPR in terms of survival rates to hospital discharge.

METHODS

We conducted a comprehensive search of electronic databases, including PubMed, from inception to October 2023, using keywords such as cardiopulmonary resuscitation (CPR), cardiac arrest, and telemedicine combined with Boolean operators. Language was restricted to English, with no date of publication restrictions. We included studies assessing the impact of DA-CPR guidance through video or audio instruction on the quality of CPR performed by bystanders in real-life and simulated environments.

RESULTS

Our research strategy yielded 537 references. After the final analysis, we selected 27 articles from the PubMed database that met our inclusion criteria. The mean age of the included participants was 37.1 years. The study presents compelling evidence in favor of video-instructed DA-CPR, showing a significant improvement in survival rates to discharge compared to audio-instructed DA-CPR.

CONCLUSION

DA-CPR plays a crucial role in the chain of survival for out-of-hospital cardiac arrest patients. Extensive research has consistently demonstrated its effectiveness in increasing bystander-initiated CPR and improving patient outcomes. Ongoing technological advancements, such as video calls and automated external defibrillator integration, continue to refine and enhance the delivery of DA-CPR. However, continuous efforts are required to standardize dispatcher training and further optimize communication strategies to ensure the highest quality of care for cardiac arrest victims.

Key Words: Cardiopulmonary resuscitation; Cardiac arrest; Telemedicine; Dispatcher-assisted cardiopulmonary resuscitation; Survival rate

Core Tip: This systematic review provides an in-depth analysis of the effectiveness of video-assisted cardiopulmonary resuscitation (CPR) compared to audio-assisted CPR. The findings conclude that video-assisted dispatcher CPR significantly enhances the quality of chest compressions and improves survival to hospital discharge. However, the implementation of video-assisted CPR may lead to delays in initiating compressions by dispatchers and presents challenges such as the need for reliable technological infrastructure and comprehensive dispatcher training.

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is a life-saving intervention used when an individual’s heart stops or beats irregularly. Dispatcher-assisted CPR (DA-CPR) is crucial in delivering prompt and adequate instructions to bystanders amidst these high-stress situations[1]. The dispatcher, frequently a skilled medical professional, directs the bystander through CPR steps until professional assistance arrives. While audio instructions have traditionally been the standard for delivering DA-CPR guidance, recent studies investigate the potential advantages of incorporating video-based instructions alongside or instead of solely audio instructions[2].

The efficacy of DA-CPR relies on the dispatcher’s ability to deliver clear, accurate, and easily understandable instructions. The dispatcher communicates essential information to the bystander, encompassing correct hand placement, compression depth, and rate while projecting a composed and reassuring demeanor. Within this framework, the instructional mode, whether solely audio or enhanced with video, emerges as a pivotal element influencing the quality of CPR initiated by bystanders[3-5].

The transition to video-based instruction in DA-CPR is grounded in acknowledging that visual information can significantly improve the comprehension and retention of intricate tasks[6,7]. Although audio instructions remain invaluable, particularly in scenarios without visual cues, video instruction introduces an extra dimension of clarity and precision. Visual cues allow bystanders to grasp the accurate hand placement, compression technique, and rhythm, offering a more tangible and intuitive understanding of the life-saving procedure[8,9]. Furthermore, video instruction in DA-CPR can potentially alleviate the risks of misinterpretation or miscommunication often associated with audio-only guidance. Challenges such as language barriers, background noise, or high-stress environments may impede the precise communication and understanding of verbal instructions. In contrast, video instructions overcome linguistic barriers by providing a universally comprehensible visual representation of the CPR process[7,10,11].

This research not only delves into the comparative effectiveness of video and audio instruction in DA-CPR scenarios but also prompts a more extensive exploration of the role of technology in enhancing emergency response protocols. With ongoing advancements in communication technology, seamlessly integrating video-based instruction into emergency medical services (EMS) procedures becomes increasingly plausible. However, a comprehensive assessment of potential logistical challenges is essential, ensuring that the advantage of these technological enhancements significantly outweighs any potential drawbacks. Recent developments in research are beginning to illuminate the comparative efficacy of video and audio instructions in the context of DA-CPR scenarios. This systematic review aims to provide persuasive evidence supporting video-instructed DA-CPR, indicating a noteworthy disparity in survival rates to discharge compared to audio instructions.

MATERIALS AND METHODS

The following systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines[12]. In October 2023, a search was conducted in the electronic database PubMed/Medline using the following command: (“cardiac arrest” OR “arrest call” OR “arrest team”) AND (“telemedicine” OR “video” OR “telecardiology”). Medical Subject Headings terms, and Boolean operators for comprehensive retrieval of relevant literature.

Eligibility criteria

Studies that estimated the impact of DA-CPR guidance through video instruction or audio instruction on the quality of CPR performed were included. The research question was designed using a Population Intervention Comparator Outcomes strategy: (1) Population: Bystanders performing CPR in both real-life situations and simulated environments; (2) Video-instructed DA-CPR; (3) Audio-instructed DA-CPR; and (4) Quality of chest compression, time-related quality parameters, correct hand positioning during CPR, survival to hospital discharge, perception of stiffness, and good neurological outcome at hospital discharge.

The studies included were either randomized clinical trials or case-control studies. Exclusion criteria included studies that did not report data or measures for our selected outcomes, studies focusing on telephonic assisted call arrest procedures, studies concentrating on audio-instructed DA-CPR only, or studies with no available full-text. Video-instructed dispatcher instructed (DI-CPR) involved visual guidance provided by dispatchers, while audio-instructed DI-CPR involved verbal guidance, both aimed at enhancing CPR performance by rescuers. The term ’bystander’ encompassed all initial responders.

Review and selection of studies

After excluding duplicates, two authors independently reviewed the titles and abstracts of all potentially relevant citations. Subsequently, a thorough assessment of the complete texts was conducted to determine their suitability for inclusion in the systematic review. Any disagreements were resolved between the authors.

Data extraction

Two authors independently recorded the relevant data into an Excel spreadsheet, including baseline characteristics and demographic information of the study populations, outcomes measured such as quality of chest compression, time-related quality parameters, correct hand positioning during CPR, survival to hospital discharge, and perception of stiffness, and good neurological outcome at hospital discharge, and details about the assessment of the risk of bias.

Quality assessment

Two investigators evaluated bias risk independently, verifying the results through cross-checking. The evaluation followed the guidelines outlined in the Cochrane Handbook version 5.1.0 for assessing bias risk in the included trial. Other designs were evaluated using the National Heart, Lung, and Blood Institute tool.

RESULTS

The search command was run on October 28^th 2023 and retrieved 537 references conducted on the. Following an initial assessment, two duplicate studies were excluded. Subsequently, a preliminary screening of titles and abstracts excluded 480 references due to not meeting the inclusion criteria. This entire process is visually represented in Figure 1 with a Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines diagram. Ultimately, 27 articles aligned with the inclusion criteria and were assimilated into the systematic review.

Figure 1  PRISMA-P Flowchart for the systematic review.

Bias was meticulously evaluated in the incorporated studies is assessed using the Cochrane risk bias tool for randomized controlled trials[13] and is graphically portrayed in Figure 2. Among the fourteen randomized control trials scrutinised, the majority exhibited low risks in domains of selection, attrition, reporting, and other biases. However, aberrancies were noted[14,15], which demonstrated elevated risks of selection, performance, and detection biases, visually represented in Figure 2.

Figure 2  Analysis of potential biases.

During the compilation of results, a few different themes emerged one being the provision of CPR through telematics such as Google glasses (GGs)[14], which showed promising results with a 100% successful defibrillation rate achieved through wearable technology. Similarly, the comparative analysis between smart glasses-video assistance (SG-VA) and smartphone-audio assistance in basic life support (BLS) tasks revealed significant enhancements with SG-VA[16]. The study concluded statistically significant results in SG-VA groups across the BLS metric such as including protocol completion, airway management, breathing assessment, automated external defibrillator (AED) pad placement, and bystander communication. Another pilot simulation study assessed the feasibility of smart glasses in providing BLS and operating an AED to fishermen in a simulated out-of-hospital cardiac arrest (OHCA) on the boat[17]. The largest difference was found in the variable “correct hand position during cardiac compressions”, with 33% incorrect hand position during CPR according to the on-scene instructor, while the dispatcher considered it correct in 100% of the participants.

The second theme prevalent through the systematic review was the use of smartphones in providing effective CPR vs conventional audio assistance and the effects of video quality on the provision of effective CPR in life-threatening medical emergencies. Plata et al’s research[18] on video-assisted CPR underscored the significance of video quality, suggesting that even low-quality video may facilitate accurate CPR evaluations. Whereas another study emphasized the importance of standardized filming protocols for effective CPR, indicating that live video communications could enhance chest compressions compared to telephone-instructed CPR protocols[19]. Moreover, a few studies investigated the effect of CPR through cellular phone livestream instruction by EMS and concluded that the live stream feature helps in the identification of correct and incorrect compression frequency, compression depth, and compression point by EMS dispatching staff during telephone-assisted CPR (T-CPR)[20]. On the other hand, a similar study compared the CPR performance between VA-CPR and audio coaching, which showed Video coaching improved CPR performance in terms of compression rate, hand positioning, and “hands-off” events, but neither group achieved the recommended chest compression depth[11]. Research on real-time communication’s effects on medical emergencies revealed expedited diagnosis times and improved bystander CPR quality with live-streaming video calls[21,22]. However, a simulation study found that remote online medical instructions had inferior effectiveness compared to on-scene medical assistance for simulated cardiac arrest scenarios[23].

Nonetheless, these findings collectively delineate the diverse landscape of technological interventions in CPR and defibrillation, each presenting distinct advantages and limitations in improving patient outcomes. The mean age of participants included in the review was 37.1 years. Tables 1-3[7-9,14-35] provides comprehensive insights into the individual studies. Table 4[7-9,11,14-35] provides a comprehensive overview of each study. This article provides a comprehensive overview of the use of telemedicine in cardiac arrest by encapsulating methodological nuances, participant characteristics, and biases inherent in the included studies, which are explained in Tables 1-3[7-9,14,31-35] (qualitative statistical analysis, part A-I), and Table 4[7-9,11,14-35] (study characteristics) respectively.

Table 1 Summary of included studies, n (%).

Ref.	Ecker et al[20], 2020			Perry et al[19], 2020			Johnsen et al[24], 2008	Lee et al[11], 2011		Peltan et al[15], 2022		Lee et al[9], 2021		Sonkin et al[21], 2022	Meinich-Bache et al[25], 2018		Kim et al[8], 2021
Comparators	Video	Audio	Control	Video	Audio	Filming	Video	Video	Audio	Telemedicine	Control	Video	Audio	Video	Video		Smartphone	BLS
Country	Germany			Israel			Norway	South Korea		United States		South Korea		Israel	Norway		South Korea
Study period	2018-2020			2018-2019			2006-2007	May 2010 to June 2010		2017-2018		2018-2019		2020-2021	2017-2018		2015-2016
Study design	Randomised controlled simulation trial			A simulation study			A simulation study	Randomised controlled simulation trial		Multicenter randomized controlled trial		Retrospective cohort study		A Simulation study	A Simulation study		Retrospective cohort study
Sample size	50	50	50	14	17	18	6	39	39	35	36	387	1722	43	19		199	417
Participants	Adult volunteers			Medical technicians			Dispatchers	Adult volunteers		Physician		adult patients with OHCA		Active paramedics	Bystander and dispatcher		Adult patients with OHCA
Inclusion criteria	Adult volunteers were recruited from the streets surrounding the hospital. Exclusion criteria included age less than 18 and more than 65 years, healthcare providers (medical practitioners, nurses, paramedics), pregnancy, cardiovascular or musculoskeletal diseases, or any other medical condition preventing performance of CPR over 8 minutes			Twenty-five emergency medical technicians acted as EMDs in the three conditions. A mannequin measured five factors that determined the effectiveness of the chest compressions			All had previously assisted CPR in their ordinary work. None of them had used video for dispatcher instructions prior to the trials	The volunteers were lay people without any previous CPR training. The subjects who had difficulty performing compression-only CPR due to their physical condition, those who were not familiar with cellularphone usage and those who had difficulty watching a video on a cellular phone due to poor vision were excluded from the study		All personnel involved in ward-based IHCA resuscitation at each study site were eligible to participate in the study. Composition and training of these ad hoc resuscitation teams varied by study site		After excluding unknown, nonbystander-witnessed arrest cases, and EMS-witnessed arrests cases (n = 2648), presumed non-cardiac etiology (n = 256), and pediatric cases (n = 28), 2109 cases were eligible for the final analysis		Active paramedics at MDA ambulance teams at the time of the study	No specefic criteria		We include adult patients (n = 18) with OHCA of medicalcauses and EMS-attended and dispatchedin. SALS isanadvanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction
Age (years)	32.92 (12.5)	37.6 (13.9)	36.7 (13.9)	NR	NR	NR	33.5	56.6 ± 7.2	55.3 ± 6.2	NR	NR	64.9 ± 16.2	72.2 ± 14.7	NR	NR	NR	82 (77-87)	80 (72-86)
BMI (kg/m2)	24.2 (5.7)	23.7 (3.6)	23.4 (3.7)	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR
Male	19 (38)	15 (30)	13 (26)	NR	NR	NR	1	20 (51.3)	19 (48.7)	NR	NR	263 (68)	1087 (63.1)	30 (70)	NR	NR	79 (39.7)	207 (49.6)
Female	31 (62)	35 (70)	37 (74)	NR	NR	NR	5	19 (48.7)	20 (51.3)	NR	NR	124 (32.0)	635 (36.9)	13(30)	NR	NR	120 (60.3)	210 (50.4)
Has provided CPR	1 (2)	1 (2)	1 (2)	NR	NR	NR	NR	39	39	NR	NR	NR	NR	32	NR	NR	NR	NR
Witnessed an emergency	5 (10)	8 (16)	6 (12)	NR	NR	NR	NR	39	39	NR	NR	NR	NR	32	NR	NR	NR	NR
Had first aid course	47 (94)	47 (94)	50 (100)	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	32	NR	NR	NR	NR

BLS: Basic life support; BMI: Body mass index; CPR: Cardiopulmonary resuscitation; EMD: Emergency medical dispatcher; NR: Not reported; IHCA: In-hospital cardiac arrest; OHCA: Out-of-hospital cardiac arrest; EMS: Emergency medical services; MDA: Magen david adom; SALS: Smartphone-based advanced cardiac life support.

Table 2 Inclusion of a summary of the studies, n (%).

Ref.	Linderoth et al[22], 2021	Ofoma et al[26], 2022		Plata et al[18], 2021	Lee et al[27], 2021			Aranda-García et al[16], 2023		Pérez Alonso et al[14], 2017		Lee et al[28], 2020		Ecker et al 2021[35]		Yang et al[29], 2009
Comparators	Video	Telemedicine	No telemedicine	Video	V-DACPR with rapid transition	V-DACPR with delayed transition	C-DACPR	Video	Audio	GG	Control	Video	Audio	Audio and video telephony		Video	Audio
Country	Denmark	United States		Germany	South Korea			Spain		Spain		Seoul, South Korea		Germany		Taiwan
Study period	2019-2021	July 1, 2017, and December 31, 2019		September 2019 to February 2020	October 2019 to July 2020			2021-2022		November 2014 to July 2015		2017		August to September 2018		2009
Study design	Retrospective study	A prospective, voluntary, multi-site registry of IHCA		Randomised controlled simulation trial	Randomised controlled simulation trial			Randomised controlled simulation trial		Randomised clinical simulation		Retrospective cohort		Prospective randomized pilot		Randomized controlled study
Sample size	90	14373	30212	93	43	45	43	14	14	36	36	231	1489	54 venues with realistic full-scale CPR mannequin		43	53
Participants	Bystander	Adult patients		Paramedics and emergency physicians	Bystander			Adult volunteers		Nurse		Emergency medical technicians		Bystander		Volunteers (bystander)
Inclusion criteria	The training included simulation-based scenarios with unconscious patients and cardiac arrest cases with a focus on high-quality CPR with simultaneously real-time guidance (video-instructed DA-CPR)	We identified 70881 patients 18 years or older with an index pulseless IHCA between July 1, 2017, and December 31, 2019. We excluded arrests at hospitals that did not respond to the AHA surveys or had missing information on TCC availability; at hospitals with less than 10 cardiac arrests over the study period; that occurred outside of an ICU or hospital ward (e.g., emergency room and operating room); and in patients with an implantable cardioverterdefibrillator. Additionally, we excluded patients with missing information related to arrest time or survival		No specefic criteria	Volunteers aged 18 years or older were recruited for the simulation trial from October 2019 to July 2020. Healthcare providers, and participants with chronic lung diseases, cardiovascular diseases, visual disabilities, or hearing disabilities were excluded during initial enrollment. Written consent was obtained from all participants			Inclusion criteria were no theoretical or practical training on BLS in the previous 2 years		Training in BLS in the last 2 years and a minimum of 2 years of professional experience in emergency services as well as familiarity with the use of AED and the ALS		OHCA patients with a presumed cardiacetiology who were more than 18 years of age between January and December 2017		NR		Ninety-six adults without CPR training within 5 years were recruited
Age (years)	21.25 (11.17)	65.5 (15.4)	65.6 (15.1)	NR	30.5 (12.0)	29.1 (10.2)	30.8 (12.1)	23	23	33 ± 8	32 ± 7	NR	NR	NR	NR	50.1 ± 11.5	50.4 ± 12.7
BMI (kg/m2)	NR	NR	NR	NR	NR	NR	NR	22.5	22.1	NR	NR	NR	NR	NR	NR	NR	NR
Male	50	8500 (59.1)	17724 (58.7)	NR	10	11	9	14	14	39%	28%	NR	NR	NR	NR	NR	NR
Female	40	5873 (40.9)	12488 (41.3)	NR	33	34	34	0	0	61%	72%	NR	NR	NR	NR	NR	NR
Has provided CPR	52	NR	NR	93	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	4 (70)	1 (90)
Witnessed an emergency	29	NR	NR	93	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	-	-
Had first aid course	48	NR	NR	93	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	18 (60)	18 (90)

BMI: Body mass index; CPR: Cardiopulmonary resuscitation; DA-CPR: Dispatcher-assisted cardiopulmonary resuscitation; NR: Not reported; IHCA: In-hospital cardiac arrest; OHCA: Out-of-hospital cardiac arrest; AHA: American Heart Association; TCC: Telemedicine critical care; ICU: Intensive care unit; V-DACPR: Video dispatcher-assisted cardiopulmonary resuscitation; T-DACPR: Telephone dispatcher-assisted cardiopulmonary resuscitation; BLS: Basic life support; AED: Automated external defibrillator; ALS: Advanced life support.

Table 3 Summaries of included studies, n (%).

Ref.	Morand et al[30], 2023		You et al[31], 2008	Barcala et al[17], 2023	Bolle et al[7], 2011		Bang et al[32], 2020			Bolle et al[33], 2009		Kim et al[8], 2021		Yuksen et al[23], 2016			Lee et al[34], 2018
Comparators	Video		Video telephony-directed	Video calls	Video	Audio	Video	Audio	Non-guide	Video	Audio	Video	Voice	Physicians		EMT	Video
Country	Switzerland		South Korea	Spain	Norway		South Korea			Norway		South Korea		Thailand			South Korea
Study period	2021		2008	2021	2011		Jun-19			December 2006 and January 2007		2020		2014			July to November 2015
Study design	NR		A prospective observational study	Descriptive and comparative design	Randomized controlled trial		Prospective randomized simulation			Clinical trial		Mixed method design		Retrospective study			Randomized trial
Sample size	28		52 public officers	16	90	90	30	30	30	180		12	12	14	14	28	48	48
Participants	Bystander		Public officers	Coastal fshermen	High school students		Laypersons			High school students		NR		Physicians, nurses and EMT			Paramedics
Inclusion criteria	NR		No previous experience with the use of a defibrillator participated in the study	Professional fishermen with at least 10 years of experience (to ensure fully familiar with the boat and with performing tasks while sailing) who had not undergone BLS training in the previous 6 months	High school students from Tromso were recruited as lay bystanders during regular school hours		Adult college students (age ≥ 18 years) and selected 90 participants who did not have formal training, such as the AHA BLS course, in CPR and AED			The study population was selected during regular school hours without prior warning		NR		NR			NR
Age (years)	NR	NR	32.7 ± 6.8	46 ± 4	17.3	17.9	22.5 (22.0-26.25)	22.0 (22.0-23.0)	26 (23.0-25.0)	17.3	17.9	22.33 ± 1.67	22.42 ± 1.98	27.64 ± 2.56	30.64 ± 4.29	29.68 ± 7.013	33 (27-42)	32 (25-43)
BMI (kg/m2)	NR	NR	-	-	-		-			-		-		-			23.4 ± 5.1	23.9 ± 4.8
Male	NR	NR	69 (20)	100%	27%	34%	43 (30)	36 (70)	40%	27%	34%	58 (30)	33 (30)	50%	42 (90)	82%	70 (80)	67 (40)
Female	NR	NR	30 (80)	0%	73%	66%	56 (70)	63 (30)	60%	73%	66%	41 (70)	66 (70)	50%	57 (10)	18%	29 (20)	32 (60)
Has provided CPR	NR	NR	-	-	-		83 (30)	70%	76 (70)	-		-		28 (60)	7 (10)	14 (30)	-
Witnessed an emergency	NR	NR	-	-	-		-			-		-		-			-
Had first aid course	NR	NR	-	-	73%	71%	-			-		-		-			-

BMI: Body mass index; CPR: Cardiopulmonary resuscitation; AHA: American Heart Association; BLS: Basic life support; CPR: Cardiopulmonary resuscitation; AED: Automated external defibrillator; NR: Not reported; EMT: Emergency medical technician.

Table 4 Individual study characteristics.

Ref.	Design	Intervention	Results	Conclusion
Ecker et al[20], 2020	Randomized controlled simulation trial	The participants received a smartphone to call emergency services, with emergency eye video-call in V-CPR group and normal telephone functionality in the other. Groups: T-CPR and V-CPR groups received standardized CPR assistance via phone	Mean compression frequency of V-CPR group was 106.4, 11.7 minutes, T-CPR group 98.9, 12.3 minutes (NS), Unassisted group 71.6, 32.3 minutes (P < 0.001). Mean compression depth was 55.4, 12.3 mm in V-CPR, 52.1, 13.3 mm in T-CPR (P < 0.001) and 52.9, 15.5 mm. In unassisted (P < 0.001). Total percentage of correct chest. Compressions were significantly higher (P < 0.001) in V-CPR (82.6%), than T-CPR (75.4%) and unassisted (77.3%) groups	CPR was shown to be superior to unassisted CPR and was comparable to T-CPR. However, V-CPR leads to a significantly better hand position than other methods. With the other study groups. V-CPR assistance resulted in Volunteers performing chest compressions with more accurate compression depth. Despite reaching statistical significance, this may be of little clinical relevance
Perry et al[19], 2020	A simulation study	A simulation study was conducted comparing CPR effectiveness under three conditions: Telephone-instructed, video-instructed, and video-instructed with the filming protocol	Compared with telephone-instructed CPR, the filming protocol improved the proportion of time in which the bystander’s hands were in the correct position during chest compressions. Compared with video-instructed CPR, the filming protocol improved the proportion of time in which the chest was fully released after each compression and the proportion. Of time in which the compressions were conducted with an appropriate rhythm. The depth and rate of compressions did not. Improve the filming protocol condition	Video-instructed CPR with the filming protocol improves CPR effectiveness compared to telephone- and Video-instructed CPR. Detailed implementation can improve new technology introduction
Johnsen et al[24], 2008	A simulation study	They used video calls and traditional phone calls for the rest	Video calls influenced the information base and understanding of the dispatchers. The dispatchers experienced that (1) Video calls help obtain information and provide, adequate functionality to support CPR assistance; (2) Their CPR assistance becomes easier; (3) The CPR might be of better quality; but (4) There is a risk of ‘‘noise’’	Video communication can improve the dispatchers’ understanding of the rescuers situation, and the assistance they provide
Lee et al[11], 2011	Randomized controlled simulation trial	Adult volunteers were randomized to receive audio-assisted instructions (audio group = 39), or video-demonstrated instructions (video group = 39)	For the video group, the chest compression rate was more optimal (99.5 minutes vs 77.4 minutes, P < 0.01), and the time from the initial phone call to the first compressions was shorter (184 seconds vs 211 seconds, P < 0.01). The depth of compressions was deeper in the audio group (31.3 mm vs 27.5 mm, P = 0.21), but neither group performed the recommended compression depth. The hand positions for compression were more appropriate in the video group (71.8% vs 43.6%, P = 0.01). As many as 71.8% of the video group had no ‘hands-off’ events when performing compression (vs 46.2% for the audio group, P = 0.02)	Instructions from the dispatcher, along with a video demonstration of CPR, improved the time to initiate compression, the compression rate and the correct hand positioning. It also reduced the ‘hands-off’ events during CPR. However, emphasized instructions by video may be needed to increase. The depth of compressions
Peltan et al[15], 2022	Multicenter randomized controlled trial	The telemedical consultant for intervention-group	No-flow fraction did not differ between the 36 intervention groups (0.22-0.13) and the 35 control group (0.19-0.10) resuscitation simulations were included in the intention-to-treat analysis (P ¼, 41). The etiology of the simulated cardiac arrest was identified more often during evaluable resuscitations supported by a telemedical intensivist consultant (22/32, 69%) compared with control resuscitations [10/34 (29%); P ¼, .001], but other measures of resuscitation quality, resuscitation team performance, and participant experience did not differ between intervention groups. Problems with audio quality or telemedicine. Connection affected 14 intervention group resuscitations (39%)	Consultation by a telemedical intensivist physician did not improve. Resuscitation quality during simulated ward-based IHCA
Lee et al[9], 2021	Retrospective cohort study	Audio-instructed DA-CPR	Favorable neurologic outcome was observed more in patients who received video-instructed DA-CPR (n = 75, 19.4%) than in patients who received audio-instructed DA-CPR (n = 117, 6.8%). The survival to discharge rate was also higher in video-instructed DA-CPR (n = 105, 27.1%) than audio-instructed DA-CPR (n = 211, 12.3%)	Video-instructed DA-CPR was significant. Associated with neurologic recovery (aOR = 2.11, 95%CI: 1.48-3.01) and survival to discharge (aOR = 1.81, 95%CI: 1.33-2.46) compared to audio-instructed DA-CPR in adult OHCA patients after adjusting for age, gender, underlying diseases and CPR location. Video-instructed DA-CPR was associated with favorable outcomes in adult patients with OHCA in a metropolitan city equipped with sufficient experience and facilities
Sonkin et al[21], 2022	A simulation study	Participants communicated with the experimenter, presenting video clips showing patients that simulated three emergency scenarios: Trauma, an unresponsive patient with cardiac arrest, and an opiate overdose	The trauma scenario was assessed most promptly, with instructions to handle the bleeding provided by all. Paramedics. In the unresponsive patient with cardiac arrest scenario, most of the participants achieved a correct initial. Diagnosis, and in the opiate overdose scenario, over half of the paramedics sought visual clinical clues for the differential. Diagnoses of loss of consciousness and their causes. Additional results show the type of assessment, treatment, and Diagnosis participants were provided in each scenario and their confidence about the situation. In the cardiac arrest scenario, the participants were assessed. the LOC in 41 (98%) sessions within a median of 1minute and 24 seconds (IQR: 00:41-02:33), evaluated breathing in 37 (88%) sessions within a median of 1 minute and 39 seconds (IQR: 00:54-03:14). The participants instructed the bystander to check central pulse in 10 (24%) sessions within a median of 3 minutes and 58 seconds (IQR: 03:06-05:20) - these participants were asked to measure the pulse only after the patient collapsed. Skin tone and sweating were assessed in 19 (45%) sessions within a median of 1 minute and 45 seconds (IQR: 01:06-02:28) and a list of the patient’s current Medications were requested in 10 (24%) sessions within a median of 2 minutes and 38 seconds (IQR: 01:25-03:17)	The findings show that direct video communication between paramedics and the scene may facilitate correct diagnosis, provision of instructions for treatment, and early preparation of medications or equipment. These may decrease time to correct diagnosis and lifesaving treatment, and impact patient morbidity and mortality. Moreover, the findings highlight the differences between incidents with higher visual clarity, such as trauma and conditions. Require an extended diagnosis to reveal, such as unresponsive patients. This may also increase the paramedics’ mental preparedness for what is expected at the scene
Meinich-Bache et al[25], 2018	A simulation study	Smartphone video analysis in real-time is feasible for a range of conditions. With the use of a web-connected smartphone application which utilises the smartphone camera	Four experiments were performed to test the accuracy of the calculated chest compression rate. Under different conditions, a fifth experiment was done to test the accuracy of the CPR summary parameters TFSCR, TC, TWC, ACR, and NC. The average compression rate detection error was 2.7 compressions per minute (± 5.0 cpm), the calculated chest. The compression rate was within ± 10 cpm at 98% (± 5.5) of the time, and the average error of the summary CPR parameters was 4.5% (± 3.6)	Real-time chest compression quality measurement by smartphone cameras are feasible for a range of bystanders, compression rates, camera positions, and noise conditions. (Is technology may be used to measure and improve the quality of telephone CPR and minimising hands-off times)
Kim et al[8], 2021	Retrospective cohort study	SALS	A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than in the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, Pb 0001)	As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and the good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved; however, those of NH patients were not significantly increased
Linderoth et al[22], 2021	Retrospective study	Live video of dispatcher-assisted CPR	CPR was provided with live video streaming in 52 OHCA calls, with 90 bystanders who performed chest compressions. Hand position was incorrect for 38 bystanders (42.2%) and improved for 23 bystanders (60.5%) after video-instructed DA-CPR. The compression rate was incorrect for thirty-six bystanders (40.0%) and improved for 27 bystanders (75.0%). Compression depth was incorrect for 57 bystanders (63.3%) and enhanced for 33 bystanders (57.9%). The adjusted odds ratios for improved CPR after video-instructed DA-CPR were hand position 5.8 (95%CI: 2.8-12.1), compression rate 77 (95%CI: 3.4-17.3), and compression depth 7.1 (95%CI: 3.9-12.9). Hands-o time was reduced for 34	Live video streaming from the scene of a cardiac arrest to medical dispatchers is feasible. It allowed an opportunity for dispatchers to coach those providing CPR, which was associated with a subjectively evaluated improvement in CPR performance
Ofoma et al[26], 2022	A prospective, voluntary, multi-site registry of IHCA	Telemedicine critical care	14373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival OR = 1.02; 95%CI: 0.92-1.15; survival to discharge OR = 0.94; 95%CI: 0.83-1.07) or outside of the ICU (acute survival OR = 1.03; 95%CI: 0.91-1.17); survival to discharge (OR = 0.99; 95%CI: 0.86-1.12). Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P = 0.37 for interaction) or survival to discharge (P = 0.39 for interaction)	Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest
Plata et al[18], 2021	Randomised controlled simulation trial	Telemedicine	No-flow fraction did not differ between the 36 intervention group (0.22-0.13) and the 35 control group (0.19-0.10) resuscitation simulations included in the intention-to treat analysis (P ¼ .41). The etiology of the simulated cardiac arrest was identified more often during evaluable resuscitations supported by a telemedical intensivist consultant (22/32, 69%) compared with control resuscitations [10/34 (29%); P ¼ .001], but other measures of resuscitation quality, resuscitation team performance, and participant experience did not differ between intervention groups. Problems with audio quality or the telemedicine connection affected 14 intervention group resuscitations (39%)	Consultation by a telemedical intensivist physician did not improve resuscitation quality during simulated ward-based IHCA
Lee et al[27], 2021	Randomised controlled simulation trial	Video call-based DACPR (V-DACPR) compared to conventional DACPR	The simulation results of 131 volunteers were analysed. The mean proportion of adequate hand positioning was highest in V-DACPR with rapid transition (V-DACPR with rapid transition vs C-DACPR: 92.7% vs 82.4%, P = 0.03). The mean chest compression depth was deeper in both V-DACPR groups than in the C-DACPR group (V-DACPR with rapid transition vs C-DACPR: 40.7 mm vs 35.9 mm, P = 0.01, V-DACPR with delayed transition vs C- DACPR: 40.9 mm vs 35.9 mm, P = 0.01). Improvement in the proportion of adequate hand positioning was observed in the V-DACPR groups (r = 0.25, P < 0.01 for rapid transition and r = 0.19, P < 0.01 for delayed transition)	Participants in the V-DACPR groups performed higher quality chest compression with higher appropriate hand positioning and deeper compression depth than the C-DACPR group
Aranda-García et al[16], 2023	Randomised controlled simulation trial	A SG-VA intervention group or a SP-AA control group	Nine of the 14 SG-VA rescuers correctly completed the BLS protocol compared with none of the SP-AA rescuers (P = 0.01). A significantly higher number of SG-VA rescuers successfully opened the airway (13 vs 5, P = 0.002), checked breathing (13 vs 8, P = 0.03), correctly positioned the automatic external defibrillator pads (14 vs 6, P = 0.001), and warned bystanders to stay clear before delivering the shock (12 vs 0, P < 0.001). No significant differences were observed for performance times or chest compression quality. The mean compression rate was 104 compressions per minute in the SG-VA group and 98 in the SP-AA group (P = 0.46); the mean compression depth was 4.5 cm and 4.4 cm (P = 0.49), respectively	Smart glasses could significantly improve dispatcher-assisted bystander performance in an OHCA event. Their potential in real-life situations should be evaluated
Pérez Alonso et al[14], 2017	Randomised clinical simulation	GG/control	Thirty-six nurses were enrolled in each study group. Statistically significant differences were found in the percentages of successful defibrillation (100% GG vs 78% control; P = 0005) and CPR completion times: 213.91 seconds for GG and 250.31 seconds for control (average difference = 36.39 seconds (95%CI: 12.03-60.75), P = 0.004)	Telematics support by an expert through GG improves success rates and completion times while performing CPR in simulated clinical situations for nurses in simulated scenarios
Lee et al[28], 2020	Retrospective cohort	Audio-instructed DA-CPR vs video-instructed DA-CPR	A total of 1720 eligible OHCA patients (1489 and 231 in the audio and video groups, respectively) were evaluated. The median ITI was 136 seconds in the audio group and 122 seconds in the video group (P = 0.12). The survival to discharge rates were 89% in the audio group and 14.3% in the video group (P < 0.01). Good neurological outcomes occurred in 5.8% and 10.4% of the audio and video groups, respectively (P < 0.01). Compared to the audio group, the AORs (95%CIs) for survival to discharge, good neurological outcome, and early ITI of the video group were 120 (0.741, 94), 1.28 (0.732, 26) and 1.00 (0.701, 43), respectively. The PSM population showed results similar to those of the original cohort	Compared to audio-instructed DA-CPR, video-instructed DA-CPR was not associated with survival improvement in this observational study conducted in one metropolitan city. Randomised controlled trials are needed to compare the effects of video- and audio-instructed DA-CPR
Ecker et al[35], 2021	Prospective randomised pilot	A video live stream from the caller’s smartphone to the EMS dispatch centre	-	This study shows that V-CPR is feasible using a video livestream from a smartphone and that typical resuscitation mistakes (which would lead to low-quality CPR) can be detected and corrected by the EMS dispatcher. Moreover, specific training of dispatchers could become necessary to achieve the best results in V-CPR
Yang et al[29], 2009	Randomised controlled study	Video cell phone with both voice and video modes	The quality of CPR was evaluated by reviewing the videos and mannequin reports. Chest compressions among the video group were faster (median rate 955 vs 63.0 minutes, P < 0.01), deeper (median depth 36.0 vs 25.0 mm, P < 0.01), and of more appropriate depth (20.0% vs 0%, P < 0.01). The video group had more “hands-off” time (5.0 vs 0 seconds, P < 0.01), longer time to first chest compression (145.0 vs 116.0 seconds, P < 0.01) and total instruction time (150.0 vs 121.0 seconds, P < 0.01)	The quality of CPR was evaluated by reviewing the videos and mannequin reports. Chest compressions among the video group were faster (median rate 955 vs 63.0 minutes, P < 0.01), deeper (median depth 36.0 mm vs 25.0 mm, P < 0.01), and of more appropriate depth (20.0% vs 0%, P < 0.01). The video group had more “hands-off” time (5.0 seconds vs 0 seconds, P < 0.01), longer time to first chest compression (145.0 seconds vs 116.0 seconds, P < 0.01) and total instruction time (150.0 seconds vs 121.0 seconds, P < 0.01)
Morand et al[30], 2023	NR	Live video tools	The first study’s results show that dispatchers are interested in visualising the scene with live video and broadcasting a live demonstration video when possible. The initial results also show that collaboration within the community is enhanced by the shared simulation and debriefing experiences, clarifying regulation procedures, and improving communication. Finally, an iterative development based on the lessons learned, expectations, and constraints of each previous study promotes the existence of a living lab that aims to determine the place of live video tools in the sequence of care performed by dispatchers	Living labs offer the opportunity to grasp previously undetected insights and redefine the use of the applications while potentially developing a sense of community among the stakeholders
You et al[31], 2008	A prospective observational study	Video telephony	Placement of the electrode pads was performed correctly by all 52 participants, and 51 (98%) delivered an accurate shock. The mean (SD) time to correct shock delivery was 131.8 (20.6) seconds (range: 101-202)	Correct pad placement and shock delivery can be performed using an AED when instructions are provided via video telephone because a dispatcher can monitor every step and provide correct information
Barcala et al[17], 2023	Descriptive and comparative design	SGs	Reliability was analysed by comparing the assessment of variables performed by the dispatcher through SGs with those registered by an on-scene instructor. Assistance through SGs was needed in 72% of the BLS steps, which enabled all participants to perform the ABC approach and use AED correctly. Feasibility was proven that the dispatcher’s feedback through SGs helped to improve bystanders’ performance, as after the dispatcher gave feedback via SGs, only 3% of skills were incorrect. Comparison of on-scene instructor vs SGs assessment by dispatcher differ in 8% of the analysed skills: Most significant difference in the “incorrect hand position during CPR” (on-scene: 33% vs dispatcher: 0%). When comparing the 1st minute with the 2nd minute, there were only significant differences in the percentage of compressions with correct depth (1st: 48 ± 42%, 2nd: 70 ± 31, P = 0.02)	Using SGs in aquatic settings seems feasible if the right wireless connectivity conditions are available. Communication between the emergency dispatcher and the witness is seamless and is especially helpful during the dispatch of the ABC approach and AED use. The small sample size did not allow us to investigate significant differences in CPR-quality markers. We consider that these devices have great potential for communication between dispatchers and laypersons but need improvement to be used in real emergencies
Bolle et al[7], 2011	Randomised controlled trial	Video calls or via ordinary mobile phone calls	Each student answered a questionnaire to assess the technology’s understanding, confidence and usefulness. The mean age was 17.3 years in the video group and 17.9 years in the audio group. There were 27% male participants in the video group and 34% male participants in the audio group. Seventy-three per cent of the students in the video group and 71% in the audio group reported previous cardiopulmonary resuscitation training	Audio-visual communication during dispatch-assisted cardiopulmonary resuscitation improved rescuers’ confidence in this study of simulated cardiac arrest. The sound quality may be a problem with current video mobile calls, but users prefer video communication despite low-quality images. The use of audio-visual communication between lay bystanders and dispatchers has the potential to improve the quality of human interaction and, thus, the quality of pre-hospital resuscitation
Bang et al[32], 2020	Prospective randomised simulation	Videocall assist laypersons	There was no significant difference among the three groups regarding baseline characteristics. Performance scores in the checklist for using AED were higher in the mobile video call-guided group, especially in the “power on AED” and “correctly attaches pads” categories, than in the other groups. However, the time interval to defibrillation was significantly longer in the mobile video call-guided group. Conclusions. Mobile video call guidance might be an alternative method to facilitate AED use by laypersons. Therefore, further well-designed research is needed to evaluate the feasibility of this approach in OHCA	In summary, this simulation evaluation confirmed that the AED performance of the laypersons improved in the video call-guided group than in the control or voice call-guided group. When using an AED alone, the AED could not be turned on quickly, and the pad could not be appropriately placed; therefore, a video call could be considered a feasible alternative in layperson CPR for OHCA
Bolle et al[33], 2009	Clinical trial	The median CPR time without chest compression (“hands-off time”) was shorter in the video-call group vs the audio-call group (303 vs 331 seconds; P 5 0.048), but the median time to first compression was not shorter (104 vs 102 seconds; P 5 0.29). The median time to first ventilation was insignificantly shorter in the video-call group (176 vs 205 seconds; P 5 0.16). This group also had a slightly higher proportion of ventilation without error (0.11 vs 0.06; P 5 0.30)	Video calls or audio calls with experienced nurse dispatchers	Video communication is unlikely to improve T-CPR significantly without proper training of dispatchers and when using dispatch protocols written for audio-only calls. Improved dispatch procedures and training for handling video calls require further investigation
Kim et al[8], 2021	Mixed method design	Video instructions vs audio instruction	Video-based instruction was found to be more effective in the number of chest compressions (P < 0.01), chest compression rate (P < 0.01), and chest compression interruptions (P < 0.01). The accuracy of the video group for the chest compression region was high (P = 0.05). Participants’ experiences were divided into three categories: ‘‘unfamiliar but beneficial experience’’, ‘‘met helper during a desperate and embarrassing situation’’, and ‘‘diverse views on drone use”	This study examined the impact of audio and video CPR instructions provided by dispatchers when an automatic defibrillator is delivered via drone during a cardiac arrest scenario outside a hospital. The research revealed significant differences between the audio and video instruction groups in various aspects of CPR performance, including chest compressions, compression rate, and hands-off time. Additionally, differences were observed in factors such as compression location, hand shape, and posture, indicating variations in CPR accuracy. Participants reported three main categories of experiences: Finding unfamiliar but helpful drone assistance, encountering assistance in a challenging situation, and having diverse opinions on drone use. These findings offer valuable insights for developing emergency medical services utilising drones and formulating video-instruction guidelines for dispatchers
Yuksen et al[23], 2016	Retrospective study	Video instruction vs on-scene medical instruction	Fourteen representative teams, 14 physicians, 14 nurses, and 28 emergency medicine technicians, participated in the study. The average ages of participants in all three occupations were between the second and third decade of life. The percentages of participants with more than three years of ambulance experience were 71%, 64.3%, and 53.6% in the physicians, nurses, and EMTs groups. The median times of all outcomes were significantly longer in the online group than the on-scene group, including times from start to chest compression (total 102 seconds vs 36 seconds), full times from the beginning to VT/VF detection (187 seconds vs 99 seconds); times from VT/VF detection to the first defibrillation (57 seconds vs 28 seconds); and times from the start of adrenaline injection (282 seconds vs 165 seconds). The percentages of using amiodarone (21.43% vs 57.14%; P value < 0.001), establishment of a definitive airway (35.71% vs 100%; P value = 0.003), and correct detections of PEA (28.57% vs 100%; P value < 0.001) were significantly lower in the online group than the on-scene group. The high-quality CPR outcomes between the online and on-scene groups were comparable	Online medical instruction may have worse CPR outcomes compared with on-scene medical instruction in shockable, simulated CPR scenarios. Further studies are needed to confirm these results
Lee et al[34], 2018	Randomised trial	Video call guidance	The median value of the time to the first defibrillation was significantly shorter in the video call guidance group (56 seconds) than in the conventional group. Group (73 seconds) (P < 0.001). The median value of the total hands-of time was also significantly shorter (228 seconds vs 285.5 seconds) (P < 0.001), the hands-of ratio, defined as the proportion of hands-of time out of the total CPR time, was significantly shorter in the Video call guidance group (0.32 vs 0.41) (P < 0.001)	Physician-guided CPR with a video call enabled prompt manual defibrillation and significantly shortened the time required for first defibrillation, hands-of-time, and hands-of ratio in simulated cases of prehospital cardiac arrest

IHCA: In-hospital cardiac arrest; NR: Not reported; CPR: Cardiopulmonary resuscitation; LOC: Level of consciousness; V-CPR: Video-assisted cardiopulmonary resuscitation; T-CPR: Telephone-assisted cardiopulmonary resuscitation; DA-CPR: Dispatcher-assisted cardiopulmonary resuscitation; OHCA: Out-of-hospital cardiac arrest; IQR: Interquartile range; TFSCR: Time to first stable compression rate; TC: Active compression time; TWC: Hands-off time; NC: Number of compressions; NH: Nursing homes; ACR: Average compression rate; SALS: Smartphone-based advanced cardiac life support; CPC: Cereberal performance category; TCC: Telemedicine critical care; OR: Odds ratio; CI: Confidence interval; ICU: Intensive care unit; V-DACPR: Video dispatcher-assisted cardiopulmonary resuscitation; C-DACPR: Called dispatcher assisted cardiopulmonary resuscitation; GC: Google glasses; SG-VA: Smart glasses-video assistance; SP-AA: Smartphone-audio assistance; BLS: Basic life support; AOR: Adjusted odds ratio; EMS: Emergency medical services; ITI: Time from call to initiation; PSM: Propensity score matching; AED: Automated external defibrillator; SD: Standard deviation; SGs: Smart glasses; VT/VF: Ventricular tachycardia/Ventricular fibrillation; PEA: Pulseless electrical activity.

DISCUSSION

The use of video calls in healthcare has experienced significant growth, particularly in critical situations like cardiac arrest, where time is of the essence. Video calls have the potential to bridge the gap between patients and healthcare providers, facilitating timely assessment, instructions, and potentially life-saving interventions. This article explores the benefits and challenges of incorporating video calls during cardiac arrest, highlighting the changing landscape of emergency response. In cardiac emergencies, swift assessment is crucial. Video calls enable real-time visual evaluation of the patient’s condition, empowering healthcare professionals to gather essential information about signs, symptoms, and the environment. This, in turn, promptly facilitates informed decision-making.

The integration of cutting-edge technology in healthcare has led to innovative approaches to delivering medical care. One such development is using GG for telematics support during CPR. Through GG, expert physicians can visually identify and promptly correct technique errors[36,37]. Studies have shown that real-time guidance in CPR, facilitated by wearable technology like GG, leads to more accurate and effective chest compressions, ultimately improving the chances of survival. Incorporating GG into standard CPR training programs can enhance the preparedness of healthcare providers for utilizing this technology during actual resuscitation scenarios. Simulated training exercises can help familiarize responders with the interface and procedures associated with GG-guided CPR[2,14].

In an observational study, the feasibility of using GG for recording inpatient cardiac arrests was explored. Simulated cardiac arrest events were recorded using in-room physician observation, stationary video camera (SVC), and GG[36]. The results demonstrated that GG successfully recorded most events and was judged superior to SVC regarding global visibility and audibility. Additionally, GG showed better interpretability compared to SVC recordings. Respondents found GG easy to use, although some expressed concerns about potential distractions during resuscitations. The study suggests that GG is a viable and acceptable method for capturing simulated inpatient resuscitation events.

In a randomized controlled study developed in a tertiary care academic medical center, forty-two first-year pediatric residents were assessed during simulated pediatric cardiopulmonary arrests using a high-fidelity manikin. The study aimed to evaluate the impact of real-time video communication via GG between the first responder and a remote intensivist on the management of in-hospital pediatric cardiac emergencies before the arrival of the intensive care unit team. During the second evaluation, residents in the GG group could communicate with a remote intensivist in real-time video, while the control group provided standard care. Results indicated that, initially, both groups exhibited high proportions of time without ventilation (no-blow fraction) at 74% and without compression (no-flow fraction) at 95%. However, in the second evaluation, while there was no significant reduction in no-blow and no-flow fractions with the introduction of GG, the technique and rate of chest compressions were notably more appropriate (P < 0.001), and insufflations were significantly more effective (P = 0.04) compared to the control group[38]. The findings suggest that real-time video communication via GG may not reduce the initial no-blow and no-flow fractions within the first 5 minutes of simulated pediatric cardiopulmonary arrests. Still, it notably enhances the quality of insufflations and chest compressions delivered.

Another randomized clinical trial to assess whether utilizing augmented reality (AR) glasses, adapted to American Heart Association (AHA) guidelines, would enhance adherence to crucial life-saving procedures during pediatric CPR compared to using pediatric advanced life support pocket reference cards. The primary outcome measured the time it took, in seconds, from the onset of a specific cardiac arrest scenario to the first attempt at defibrillation. Secondary outcomes included the time taken for chest compressions, subsequent defibrillation attempts, drug administration, and intervals between various procedures, all evaluated against AHA guidelines. The trial included twenty residents divided into two groups. Surprisingly, the use of AR glasses did not significantly improve the time taken for the first defibrillation attempt (with an average of 146 seconds) or adherence to AHA guidelines in terms of other critical resuscitation actions and drug dosages. However, notable improvements were observed in accuracy and adherence when administering defibrillation doses compared to using pediatric advanced life support pocket reference cards. Notably, without AR glasses, residents administered incorrect doses in 65% of cases, including 21 instances of shock overdoses exceeding 100 Joules, resulting in a cumulative defibrillation dose of 18.7 Joules per kilogram. The use of AR glasses led to a significant reduction in these errors by 53% and a 37% decrease in the cumulative defibrillation dose[39].

Smart glasses have emerged as a potentially transformative technology in various fields, including healthcare. In the context of CPR, these innovative devices have the potential to enhance the evaluation of CPR quality significantly. One of the most significant advantages of using smart glasses during CPR is their ability to provide real-time feedback to the rescuer[40]. Equipped with AR displays, smart glasses can overlay essential metrics such as compression depth, rate, and recoil quality directly in the rescuer’s field of vision. This immediate feedback enables rescuers to make timely adjustments, ensuring optimal CPR performance[10]. Smart glasses can assist in reducing rescuer fatigue by providing continuous guidance on compression techniques. Proper form and technique are crucial in sustaining effective compressions over extended periods. Smart glasses help maintain good form, reducing the risk of rescuer and compression fatigue. Smart glasses can record and analyze CPR performance metrics, providing objective data for assessment and training purposes. This data can be invaluable for healthcare professionals, allowing them to identify areas of improvement and tailor training programs accordingly. They can serve as valuable training tools for both novice and experienced rescuers. They can simulate various CPR scenarios, providing a hands-on, interactive learning experience. This technology can potentially revolutionize CPR training by offering immersive, realistic simulations. However, they faced several limitations because smart glasses can be expensive, potentially limiting their widespread adoption, especially in resource-constrained settings. Ensuring affordability and accessibility is crucial for maximizing their impact on CPR quality evaluation[17]. Moreover, another study, utilizing smart glass technology for remote expert assistance has the potential to enhance resuscitation outcomes. This technology allows students to begin resuscitation promptly, operate a defibrillator efficiently, and deliver defibrillation sooner. In clinical settings, nurses could leverage smart glass to improve the effectiveness of CPR, leading to better patient care[41].

Another significant emergency response and CPR advancement is T-CPR. It plays a critical role in enhancing guided bystander CPR. T-CPR plays a pivotal role in OHCA scenarios. It enables dispatchers to guide bystanders through life-saving interventions, potentially bridging the critical time gap before professional medical help arrives. The concept of T-CPR emerged in the late 20^th century[42], coinciding with the widespread availability of telecommunication networks. One study focused on T-CPR, which involved emergency dispatchers guiding bystanders in performing CPR during OHCA[43]. While T-CPR instructions had been shown to boost bystander CPR rates, there was a lack of standardized evaluation methods. The researchers analyzed audio recordings of OHCA calls from a large regional dispatch center over one year. The results showed high agreement among evaluators in most reporting metrics. Recognizing the need for CPR, dispatchers initiated T-CPR instructions in nearly one-third of cases, resulting in bystander CPR in about 14%. The study emphasized the importance of a standardized methodology for evaluating TCPR to enhance quality, establish performance benchmarks, and guide future research on improving bystander CPR rates and OHCA survival.

Subsequent research has consistently affirmed the efficacy of T-CPR in enhancing survival rates. For instance, Culley et al[5] aimed to evaluate the impact of a T-CPR program in King County, explicitly focusing on bystander CPR rates and dispatcher-related delays in providing CPR instructions over the phone. The research spans from 1976 to 1988, incorporating a cardiac arrest surveillance system and the review of 267 recorded calls reporting cardiac emergencies in 1988. Following the implementation of the dispatcher-assisted telephone CPR program, the rate of bystander CPR increased significantly from 32% (1976-1981) to 54% (1982-1988), although a direct increase in survival rates was not demonstrated. Dispatcher response times were assessed, showing that it took a median of 75 seconds to identify the issue, with subsequent delivery of early protocols, ventilation, and compression instructions taking 19 seconds, 25 seconds, and 30 seconds, respectively - the total time to convey the entire CPR message they have averaged 2.3 minutes. Notably, the most common cause of delay was unnecessary questions, accounting for 57% of delays, with inquiries about the patient’s age being the most frequent (32%).

While T-CPR has proven invaluable in many situations, it is essential to acknowledge its limitations. Understanding these constraints allows for better refinement and optimization of T-CPR programs. One of the primary limitations of T-CPR is the absence of physical presence. Unlike professional first responders, dispatchers cannot assess the victim’s condition directly, which can sometimes lead to challenges in accurately gauging the severity of the situation. This absence of visual cues may result in delays or errors in providing instructions. Effective communication is crucial during a cardiac emergency. However, language barriers, technical issues, or the caller’s emotional state can impede clear and concise communication between the dispatcher and the bystander. This challenge is particularly pronounced in diverse or multilingual communities[44]. T-CPR primarily focuses on guiding bystanders verbally through the CPR process. While this is highly effective for chest compressions, it does not allow for direct guidance on other interventions that may be necessary, such as airway management or defibrillation. This limitation can impact the overall quality of care provided. Dispatchers cannot directly observe the effects of bystander-initiated CPR. They rely on the caller’s descriptions, which may not always be accurate or detailed enough. This inability to assess the effectiveness of interventions in real time can hinder decision-making and potentially delay critical actions. The quality of T-CPR instructions depends heavily on the training and experience of the dispatcher. While many dispatch centers provide rigorous training, there can be variability in the level of expertise among individual dispatchers. This can lead to inconsistencies in the quality of T-CPR provided across different emergency call centers. Dispatchers need to manage caller anxiety and maintain focus on providing clear guidance. Some cardiac emergencies may involve unique or complex circumstances that require specialized interventions beyond standard CPR protocols. Providing CPR to pediatric patients requires technical knowledge and techniques. Dispatchers may face added challenges in guiding bystanders through pediatric CPR, especially if the caller is unfamiliar with pediatric resuscitation procedures[45].

The main focus of this study is the video calls for DA-CPR. This innovative approach leverages video communication technology to enhance the quality and effectiveness of CPR interventions guided by dispatchers. This discussion will explore the various aspects, benefits, challenges, and future potential of using video calls in DA-CPR. Video calls empower bystanders with limited medical training to perform CPR effectively. Through live guidance from healthcare providers, bystanders can receive step-by-step instructions to ensure proper chest compressions and rescue breathing techniques. Healthcare providers can prepare the receiving hospital by providing critical patient information obtained through video calls. This includes vital signs, rhythm analysis, and any specific patient history or medications, enabling the hospital team to mobilize resources and plan interventions.

Video calls serve as an invaluable tool for education and training. Dispatchers can use live video feeds to demonstrate CPR techniques, ensuring callers understand the required actions[46]. This can be particularly beneficial for individuals who may not have prior CPR training. Video calls can help calm the rescuer by directly connecting with a professional dispatcher. Seeing and hearing the dispatcher can instill confidence and reduce panic, especially in high-stress situations like cardiac arrests. In complex cases, video calls can facilitate consultation with medical experts who can provide additional guidance and recommendations. This is particularly valuable when specialized knowledge or interventions are required[11].

Bolle et al[7] conducted a study to determine if video calls on mobile phones could enhance the confidence of lay rescuers during simulated cardiac arrest scenarios. They involved 180 high school students who were randomly divided into three groups. Some communicated through video calls, while others used regular mobile phone calls, all receiving guidance from experienced nurse dispatchers. After the scenarios, each student completed a questionnaire to evaluate their comprehension, confidence, and perception of the technology. On average, participants in the video call group were around 17.3 years old, slightly younger than those in the audio call group (average age of 17.9 years). Most rescuers in both groups believed video calls were more effective than audio calls in medical emergencies. This preference was significantly more robust in the video call group (P = 0.0002). The study concluded that visual contact through video calls increased rescuers’ confidence in stressful emergencies.

Lee et al[9] investigated whether video-instructed DA-CPR provided better neurologic recovery and survival to-discharge outcomes compared to audio-instructed DA-CPR in adult OHCA cases in a well-equipped metropolitan city. The research in Seoul, South Korea, analyzed data from adult bystander-witnessed OHCA cases between January 2018 and October 2019. The study included 2019 adult OHCA patients who received DA-CPR. Video instruction was more commonly given to elderly patients and those outside a home or medical facility. Patients who received video-instructed DA-CPR demonstrated higher rates of favorable neurologic outcomes (19.4%) and survival to discharge (27.1%) compared to those who received audio-instructed DA-CPR (6.8% and 12.3%, respectively). After adjusting for factors like age, gender, underlying diseases, and CPR location, video-instructed DA-CPR was found to be significantly associated with improved neurologic recovery (2.11 times higher) and survival to discharge (1.81 times higher) compared to audio-instructed DA-CPR.

A previous meta-analysis by Lin et al[47] aimed to compare the effectiveness of video-assisted and audio-assisted DI-CPR on bystander CPR quality. The subsequent analysis involved a meticulous examination of the disparities in DI-CPR quality under both video and audio guidance. The outcomes revealed noteworthy distinctions between the two groups. Notably, the initiation of chest compressions displayed a slower response in the video-assisted group compared to their audio-assisted counterparts, showcasing a median delay of 31.5 seconds. Additionally, the video-guided group exhibited a significantly higher chest compression rate, surpassing the audio-guided group by 19.9 compressions per minute. There was a slight preference for the audio-guided group regarding correct hand positioning, though this distinction did not reach statistical significance. Similarly, chest compression depth and time to first ventilation exhibited minimal differences between the two groups. In conclusion, this study underscores the importance of dispatcher-instructed CPR and offers valuable insights into the effectiveness of video and audio guidance in real-time resuscitation efforts. The findings indicate that video-assisted DI-CPR substantially enhances the chest compression rate compared to its audio-assisted counterpart. A discernible trend was also towards better hand positioning with video guidance. However, it is crucial to acknowledge that the video-assisted method did introduce a delay in initiating bystander-initiated CPR within simulated settings.

Another meta-analysis by Bielski et al[4] aimed to assess the effectiveness of video-guided dispatcher-assisted bystander CPR (V-DACPR) in contrast to the traditional method of audio-guided dispatcher-assisted bystander CPR (C-DACPR). Compared to the C-DACPR, the V-DACPR significantly enhanced the chances of prehospital return of spontaneous circulation and survival upon hospital discharge. In simulated resuscitation scenarios, V-DACPR demonstrated a higher rate of effective chest compressions than C-DACPR. As mentioned by Ecker et al[35], out of the 17 video calls, a proper compression depth within the recommended guidelines (5-6 cm) was accurately identified in 12 instances, accounting for 70.6% of the cases. Yang et al[29] showed that the video group had a deeper compression with a median depth of 36.0 mm compared to 25.0 mm in the audio group. This difference was statistically significant (P < 0.01). Concerning the Proportion of chest compressions with appropriate depth, Yang et al[29] reported that the proportion of chest compressions with appropriate depth was higher in the video group, 20.0% (2-55) vs 0% (0-28.55). This highlights the substantial impact of dispatcher support and the assistance method provided on bystander CPR outcomes.

In this article, we conducted a thorough assessment of existing literature on the enhancement of DA-CPR quality through video instruction. Nevertheless, we encountered certain constraints. For instance, we incorporated studies with various methodologies, populations, and interventions. This diversity challenges arriving at unequivocal conclusions, particularly when endeavoring to amalgamate data from studies employing fundamentally different approaches. Furthermore, disparate studies employ varying outcome measures to evaluate the same intervention or phenomenon. This divergence makes direct comparison and synthesis of results intricate, potentially resulting in discrepancies in the review’s findings. Improving training programs and standardizing protocols may enhance the effectiveness of DA-CPR and lead to better patient outcomes, ensuring consistent care. Future efforts should prioritize incorporating support tools such as video calls, expanding retraining initiatives, and implementing structured follow-up and debriefing processes[33]. Also, video-assisted CPR could serve as an inclusive educational tool for teaching CPR to the deaf community[40].

Also, through this systematic review, we identified infrastructure and technological barriers that limit the adoption of audio and video communication. For instance, a vast majority of people lack access to high-speed internet. Despite its effectiveness, audio-instructed dispatcher-assisted CPR is not without challenges. Variability in dispatcher training and experience can influence the quality of instructions provided. Additionally, factors such as caller anxiety, language barriers, and environmental noise levels can hinder effective communication, highlighting the need for ongoing dispatcher education and training[44]. In developing countries, the situation is further complicated by the lack of basic infrastructure. Many low socio-economic areas lack broadband, landline services, and a reliable electricity supply, making it difficult to deliver audio- or video-assisted medical services.

However, satellite solutions such as the Satisfaction with Medicines platform can provide telemedical services to remote areas, but these initiatives require significant investment and coordination between governments and technology providers. Moreover, the coronavirus disease 2019 pandemic highlighted the challenges people faced in adapting to new technological tools. This technological transition had significant implications for patient safety, health equity, and quality of care. Patients with low digital literacy struggled to adapt to the sudden shift toward telehealth, leading to varying health outcomes. As technology advances, future research should focus on optimizing the integration of video calls into dispatcher-assisted CPR protocols. This may involve the development of user-friendly interfaces, addressing privacy concerns, and exploring the potential for augmented reality or other emerging technologies to enhance real-time guidance.

CONCLUSION

DA-CPR is a critical link in the chain of survival for OHCA patients. Extensive research has demonstrated its effectiveness in increasing bystander-initiated CPR and improving patient outcomes. Advances in technology, such as video calls and AED integration, continue to refine and enhance the delivery of DA-CPR. However, ongoing efforts are needed to standardize dispatcher training and improve communication strategies to ensure the highest quality of care for cardiac arrest victims.