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.
It was agreed with high consensus, that Community First Responders save lives. This conclusion is supported by an observational study showing an increased survival to hospital discharge, if OHCA was attended by at least one first responder(16).
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(28). Additionally, the dispatch centre can evaluate for each situation, whether the dispatch of a CFR is safe(29). In systems working detached from EMS dispatch centres, there is no specific risk assessment of each mission. Some SBA systems allow activation of CFR by both medical laypersons and emergency medical dispatch centres(30).
Consensus was also found on enabling communication between CFR and EMS dispatcher during the mission, with both being able to initiate contact. Studies done in CFR-system working without SBA, showed that some CFR appreciated support during a mission(31) and found lack of information stressful and frustrating(32). 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, funding and mode of activation of CFR(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). 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. Efforts should be taken to offer such technique also on national and international levels elsewhere.
Diversities between different CFR systems arose due to different backgrounds, geographical and infrastructural conditions. A Swedish study on dispatch of firefighters alerted without smartphone app 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(33). Hence, we might need to adapt CFR systems to differing regional demands (28). One approach in rural areas could be to build a tighter net by also including medical laypersons as CFR.
The inclusion of medical laypersons as first responders was discussed controversially. The obvious benefit of a tighter net of CFR 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(34, 35). Bystander CPR initiated by medically trained CFR instead of laypersons was associated with higher 30-day-survival(36).
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(13, 37). In the Italian system CFR get instructions on chest compressions by the dispatch centre whilst attending an OHCA(37).
Training is perceived as fundamental by the first responder and some feel that training shows that the organisation values their effort(31). Most CFR are in favour of scenario-based learning(31, 38). Accordingly, the consensus panel disapproved of e-learning without face-to-face training.
It’s uncertain which other aspects, apart CPR, should be addressed during training. A focus should also be put on safety
(32)
. 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(5, 7, 31). Working as CFR can be traumatic and emotionally stressful(5, 6). 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(39).
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(40). First responders found CPR on children to be more distressing than on adults(32). 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(31). When determining, which emergencies first responder should attend, need for additional training and equipment should be considered. Basic life support requires only minimal equipment, e.g. gloves. 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. 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, 18). However, picking up an AED may lead to a delay in CPR(41), 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(42).
Funding of CFR programmes differ, even within one country(6). Systems typically depend on fundraising or receive, to some degree, statutory funding(31). 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 fund CFR is to implement it into existing EMS structures. 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, 43).
A collaboration with well-established non-governmental first aid organisations may be beneficial to promote CFR systems. To recruit new CFR, participation has to be actively promoted and advertised; first responders frequently discover CFR programmes via promotion material or by talking to CFR(10, 13, 31). Commitment to being a CFR should be actively supported(44).
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), which might help to retain CFR.
Regular meetings of the CFR group may also 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(12, 17, 43).
Limitations of the study
The chosen format entails a few limitations. The conference was held in German and English, which implies a certain language bias.
Despite our best efforts to engage with all stakeholder groups the participants may not reflect the target population properly. Nevertheless, we managed to recruit a variety of opinion leaders and stakeholders from different backgrounds. Some participants might have had a higher impact on others during the discussion, which we had anticipated and which we have tried to mitigate through the workshop leads, who ensured that all participants were heard during the discussions. The voting process also mitigated the influence of strong opinion leaders. Voting results reflect the opinion of the stakeholders who participated in the voting session.
Transferability of the data may be 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. Despite the limitations of the chosen format, this is, to our knowledge, the first consensus process, bringing together stakeholders from various backgrounds and integrating scientific evidence, the views of the public, the political decision makers and the health care budget holders.