During the conference, the consensus panel had the opportunity to compare different CFR systems implemented in five European countries (Denmark, The Netherlands, Germany, Switzerland, and Austria). Pros and Cons of the different approaches were discussed. The debate and voting reflected the wide variety between the different systems and even opposing opinions in some aspects. Hence, consensus could only be found in 5 out of 25 generated statements.
The vast majority agreed with a high consensus, that Community First Responders save lives. This conclusion is supported by the current literature(28–30, 16, 24). A recent study revealed higher hospital discharge rate as well as improved neurological outcome in patients treated by CFR dispatched by SBA(31).
Approval with high consensus was also found for the statement, that activation of CFR should be done by EMS dispatch centres. Deployment of CFR by the dispatch centres offers better integration into the EMS system(32). Additionally, the dispatch centre can evaluate for each situation, whether the dispatch of a CFR is safe(33). Depending on local protocols, dispatch centres may not dispatch CFR on potentially hazardous missions, e.g. road traffic accidents or crime scenes(33). In systems working detached from EMS dispatch centres, there is no specific risk assessment of each mission. Hence, these systems rely on the person, who alerts the CFR, as well as the CFR to judge the situation. Some SBA systems allow activation of CFR by both medical laypersons and emergency medical dispatch centres(34).
Consensus was also found on enabling communication between CFR and EMS dispatcher during the mission, with both being able to initiate contact. Some CFR appreciate support during a mission(35). First responders such as police and fire fighters reported lack of information as stressful and frustrating(36). Hence, the possibility to contact the dispatch centre to check back or gain further information might alleviate the stress level of CFR.
Consensus was found on the need for a national strategy. Currently, a multitude of successful CFR systems exists worldwide, which differ in several aspects, e.g. technology, training scope and funding(6, 17). Even within single countries, varieties of CFR systems exist(7, 17). This diversity could negatively affect effectiveness, safety and retention of personnel(7). The high Dutch OHCA survival rates are attributed to a nationwide alert system that dispatches primarily BLS trained laypersons but also professional responders as fire service and police(16). Without a nationwide strategy and cooperation between SBA operators, CFR registered in one system not necessarily register in another system. Thus, Switzerland has launched a national project in January 2020 linking cantonal SBA systems with a national mobile app. While domestic CFR are alerted through their own cantonal SBA system, visiting CFR from neighbour cantons are simultaneously engaged through the national app. As a result, CFR registered in one canton no longer need to register in another canton as well. It would be great, if such technique would also be available on national and international levels elsewhere.
Diversities between different CFR systems arose due to different backgrounds: While some CFR programmes were strategically initiated by health care authorities in areas with risk of shortage, others are citizens' initiatives(6). Furthermore, geographical and infrastructural conditions influence the systems, and distinctions have to be made between rural and urban areas(17). A Swedish study on dispatch of firefighters analysed the impact of population density: In rural areas the relative reduction in median time until first chest compression was greater than in urban areas. However, the increase of 30-day-survival was much higher in densely populated areas(29). Hence, we might need to adapt CFR systems to differing regional demands (32). One approach in rural areas could be to build a tighter net by recruiting not only CFR with a medical background, but also laypersons, because there are not enough medically trained CFR to cover rural areas sufficiently(37). This clearly is a field for further research.
The inclusion of laypersons as first responders was discussed controversially. The obvious benefit of a tighter net of CFR by including laypersons has to be balanced with the counteracting aspect, that quality of CPR may not be as good in laypersons as in professionals. There are indications that survival rate of OHCA is doubled if bystander CPR is performed by medically trained personnel instead of laypersons(38, 39). An analysis of the Swedish Registry of Cardiopulmonary Resuscitation showed that bystander CPR initiated by medically trained CFR instead of laypersons was associated with higher 30-day-survival(40).
Most members of the consensus panel agreed, that a person needs basic knowledge of CPR to become CFR. Yet, systems successfully implemented in Singapore and Italy are open for laypersons without any training in CPR(41, 13). In the Italian system CFR get instructions on chest compressions by the dispatch centre whilst attending an OHCA(41).
Training of first responders is an essential element of any CFR system, although focus and content differ significantly(6). Training is perceived as fundamental by the first responder and some feel that training shows that the organisation values their effort(35). Most CFR are in favour of scenario-based learning(35, 42). Accordingly, the consensus panel disapproved of e-learning without face-to-face training.
Practising CPR regularly is key. Some lay CFR feel, they need higher competence levels(6). The ideal timespan to refresh CPR training is unknown. Although retraining is perceived to be an organisational hurdle, CFR would like to receive ongoing training(35). If no training was offered for a longer period, CFR feared a decline in competence and felt, that they weren’t supported and appreciated enough(43). Furthermore, they felt, that training becomes less effective, if they are not dispatched to OHCA regularly(35).
It’s uncertain which other aspects, apart CPR, should be addressed during training. A focus should also be put on safety(36). Because confidentiality is a major concern, legal aspects are recommended(6). In addition, CFR would also like to receive training in communicational skills and dealing with emotional aspects(7, 5, 35). Working as CFR can be traumatic and emotionally stressful(5, 6). Even medical experts sometimes feel stressed while working as CFR(44). Some police officers and firefighters described treatment of OHCA as horrible or depressing and stated, that they often think about it afterwards(36). Strain may be additionally increased, if CFR know the patient(35, 6). Also, younger CFR may experience higher stress levels. Hence, it is unclear, if there should be a minimum age to become a CFR. Most systems in Europe operate an age threshold of 16 years(17). Focused training for CFR could help alleviate the psychological burden. A Dutch study showed, that even if lay rescuers experience severe stress and short-term psychological impact, no symptoms of post-traumatic stress disorder could be detected 4 to 6 weeks afterwards(45).
During the consensus conference, there was an in-depth debate, whether CFR should also attend paediatric OHCA. While some systems also alert to paediatric OHCA, most do not(17, 46). First responders found CPR on children to be more distressing than on adults(36). Albeit, children might benefit most from early resuscitation by CFR.
It was discussed in great detail, if CFR should be dispatched only to OHCA or to other medical emergencies as well, and no consensus could be found. While most CFR systems dispatched initially only to OHCA, the role of CFR has increased over time(35). Nowadays, CFR in UK are mainly dispatched to OHCA, but also answer to unconscious patients, diabetic emergencies, seizures, and breathing difficulties(8, 6). The CFR system in Lincolnshire, UK, works with different levels of expertise ranging from basic life support to complex trauma care(35). When determining, which emergencies first responder should attend, several aspects should be considered. One is, that special training is needed. CFR might feel overly challenged by emergencies other than OHCA(36). Another aspect is, that additional equipment is needed. CPR requires only minimal equipment, like gloves and face shields. Thus, CFR can approach the emergency site without needing to collect a special kit. In contrast, treatment of other emergencies requires additional equipment and CFR may need to detour. The major benefit of CFR systems is time advantage in relation to EMS. Hence, taking a detour would impair this. Some systems also include automatic external defibrillators (AED), because a dispatch of first responders equipped with AED was found to lead to earlier shock and increased survival(4, 11, 25, 23, 18). However, picking up an AED may lead to a delay in CPR(47), especially in areas with low population densities and limited availability of AED. Results from a Dutch study indicate, that the optimum constellation is more than ten First Responders and 2 AED per square kilometre(48).
Funding of CFR programmes differ, even within one country(6). Systems typically depend on fundraising or receive, to some degree, statutory funding(35). In systems depending on fundraising, first responders are often involved in the process of raising money(35). During the consensus process some participants suggested, that CFR programmes should be laid down in the social security code and financed by health insurance funds or on an interim basis within the federal state law.
One possibility to finance CFR is to implement it into the existing emergency medical system (EMS). Currently, some CFR systems are part of the EMS, while others are complementary or totally separate from the EMS and sometimes they replace EMS (remote areas in Iceland)(9, 17, 49). This is often confusing for CFR as well as for the public(6). One benefit of integrating CFR into the EMS might be, that CFR feel more comfortable in their role(6). However, other CFR would prefer to be complementary support and not an expansion of statutory service(35).
A collaboration with well-established non-governmental first aid organisations may be beneficial to promote CFR systems. The public may fear that CFR programmes are merely a substitute for EMS struggling to meet their time targets. This could hamper recruitment(43, 6). Some CFR systems perceived the need for closer involvement from the stakeholders, particularly the public(7). To recruit new CFR, participation has to be actively promoted and advertised; first responders frequently discovered CFR programmes by publicity material or by talking to CFR(35, 10, 13). In most studies, participants became CFR for altruistic reasons, to support the community or to improve expertise in emergency medicine(7, 10). Some became CFR because they had witnessed an emergency(10). Commitment to being a CFR should be actively supported(43).
A way to increase public recognition, would be to announce all resuscitations performed by CFR. In general, the community wants to be better informed about CFR(6). Additionally, many first responder expect praise for their help(7). This might help retaining CFR in programmes. Some CFR voiced, that they miss recognition of their work by the community, which led to frustration(35).
Regular meetings of the CFR group may help to increase retention(9). CFR who have not been dispatched for a longer period may get demotivated(10). CFR groups with regular meetings were found to have higher cohesion and motivation(10). Thus, a platform for communication and training is recommended.
It remains unclear whether a system with many unqualified responders delivers better outcomes than a system with a few highly qualified CFR. Hence, in some countries, like UK, systems with a small number of medical professionals coexists with systems with a large number of medical laypersons(9). Lessons learned from the different systems worldwide might help us answer this question and randomised controlled trials are needed(17, 12, 49).
Limitations of the study
The findings shown in this paper are based on a consensus conference held in Germany. Another conference location or further conference languages in addition to German and English might have led to a higher number of persons joining the consensus panel. Transferability of the data might be further limited, because focus was laid on CFR systems in Europe. A consensus process condenses complex aspects, which has the potential drawback of overgeneralisation. However, a consensus process offers an opportunity to analyse the current state and identify areas, which need further evaluation.