Influencing factors of telephone-cardiopulmonary resuscitation in China: a qualitative exploration based on managerial perspectives

Background Telephone-cardiopulmonary resuscitation(T-CPR) has been proven to systematically improve bystander CPR implementation and thus improve the survival rate of out-of-hospital cardiac arrest (OHCA) patients on a large scale. However, China has a lower proportion of cities that provide T-CPR than other countries.This study aimed to explore the factors affecting the providing of T-CPR based on managerial perspectives and promote the implementation of T-CPR in China to Protect human health. Methods This study adopted a descriptive qualitative method.The managers from health bureau and first-aid Center were recruited to participate through purposive sampling. Data were collected using semi-structured interviews and Colaizzi 7-step analysis method was adopted to summarize and conclude the theme. Results A total of 10 managers were interviewed.Five main themes were identified: (a) bystander factors, (b) dispatching factors, (c) legal factors, (d) guiding factors, and (e) financial factors. Conclusion It is urgent to promote the implementation of T-CPR in China.We can promote it by strengthening the training of bystanders in CPR knowledge and skills, developing T-CPR guidance process suitable for Chines national conditions, building an intelligent prehospital emergency system, promoting the legislation of first aid exemption, and providing financial support from various channels.


INTRODUCTION
Out-of-hospital cardiac arrest (OHCA) is the most urgent and dangerous public health issue in the world (Benjamin et al.,2017;Miller & Falk,2020;Høybye et al., 2021).Modern medicine has fully proved that 4 to 6 minutes after cardiac arrest is the golden time for rescue, but it is difficult for ambulances to arrive at the scene in the golden time. Therefore, whether the public implement cardiopulmonary resuscitation (CPR) or not and the quality of CPR have a significant impact on the survival rate of OHCA patients (Sutter et al.,2015).Because the witnesses are often non-professional medical personnel, they will not really administer effective CPR for patients with cardiac arrest because they are not confident in their own CPR skills, afraid of the implementation of mouth-to-mouth artificial respiratory infectious diseases, panic, and have not learned CPR (Becker et al.,2019;Hagihara et al.,2018).So that patients miss the best time to rescue and lead to serious consequences, bringing heavy burdens to society and families.
In order to increase bystander cardiopulmonary resuscitation (B-CPR) and to improve patient outcomes, American heart association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC) clearly point out that the first witnesses who have never received CPR training or who have received training but failed to successfully initiate CPR in the first time should be instructed by dispatchers through telephone to implement CPR (T-CPR) (Dobbie et al.,2018).T-CPR enables some first-time witnesses who have never received CPR training to implement CPR under the guidance of the dispatcher's telephone, thus Canada, Switzerland and Norway (Kleinman et al.,2015;Bobrow et al.,2016;Shimamoto et al.,2015).But T-CPR is seldom carried out in China, only in a few cities such as Suzhou and Foshan.China, a country with 4/1 of the world's population, in order to improve its popularity of T-CPR and the success rate of on-site rescue, and to reduce the mortality and disability rate after cardiac arrest, our study is based on managerial perspectives (Health Bureau, Fist-aid Center and other management personnel) who will play a key role in carrying out TCPR, and through a qualitative study to explore the factors affecting the providing of TCPR, especially finding out the possible obstacles, so as to promote the implementation of TCPR and play a role in promoting human health.In addition,it can effectively solve the occupational problems related to the field of pre-hospital emergency care to improve the occupational environment of occupational health care workers.

METHODS
Our main aim was to identify influencing factors of telephone-cardiopulmonary resuscitation in China based on managerial perspectives.

Participants
A purposive sampling approach, was used to select the managers were recruited from health bureau and first-aid Center.The sample size is based on the principle of information saturation.Finally, a total of 10 managers consented to participate in the study. The inclusion criteria were: (a) managers from health bureau and first-aid Center aged 18-60, (b) worked in this management for more than 2 years, (c) could understand and communicate in Chinese, (d) agreed with the interviewees. The exclusion criteria were: (a) mental disorders and/or cognitive impairment, (b) unable to complete the study due to physical condition, (c) unable to perform CPR due to physical disability or other reasons.

Study design and methodology
The study adopted a descriptive qualitative method.Data were collected by using semi-structured interviews through face-to-face or by telephone. The interview outline

Data collection
The face-to-face interviews lasted from 20-50 minutes (mean±SD: 32.5) and were conducted in a location chosen by the participants.We collected data by means of a semi-structured interview, and all sessions were audio-recorded.At the beginning of the interviews, the researcher introduced herself and explained the purpose and significance of this study to the participants. After obtaining the formal consent of them, the informed consent was signed. The researcher remained neutral and avoided making any judgment on the interview contents.The privacies of the participants were protected, and the name was replaced by the code.

Data analysis
After one interview was completed, the recording was transcribed verbatim into text within 24 hours. The data were analyzed concurrently with the data collection using the Colaizzi 7-step analysis method. The first step involved reading the full interview transcript several times to have a comprehensive understanding of the participant's experiences. Then, any narrative data related to the impact of the T-CPR implementation were hand-coded line-by-line. Next, generated the theme based on the similarities and differences between the code and the concept. Finally, created a definition for each theme and selected the support references from the data. The data collection and data analysis procedures were conducted repeatedly until there was no more topic (Glenn & Bowen,2008).

Ethical considerations
We obtained approval by the ethical committee of the institutions(20200529-1) for this study. All participants were recruited as volunteers. Before the interviews, participants were given a participant information sheet with written information on the project and provided informed consent. All reports were kept private and confidential.
Code numbers were used in this article to identify individual comments.

Rigour
Four criteria, including credibility, dependability, conform ability, and transfer ability, were used to evaluate the rigor of the qualitative research.Interviews were audio-recorded to ensure credibility and to ensure that participants' responses were captured accurately. In addition, participants' statements were probed and clarified to ensure that they were understood accurately. An audit trail based on the interview outline, audio-recordings, transcripts, field notes, and data analysis process was clearly elaborated. Dependability and conform ability were also established by having decisions relating to the study made by two other researchers in the team. Other than the primary researcher, two researchers who were experienced in the field of study were involved in data analysis.

RESULTS
Participants (n=10) were predominately male, Han Chinese, married, and between the ages of 40 and 50 years (see Table 1

Factors associated with weak awareness of first aid and low level of cardiopulmonary resuscitation of bystanders
At present, there is still a big gap in the awareness and level of first aid among Chinese residents compared with the developed countries. The national consciousness of first aid is so weak, and the basic knowledge of first aid is not valued. In a word,if bystanders have never been exposed to CPR learning, it is difficult to do so by telephone.

Factors associated with unstable emotions of bystanders
Bystanders will feel fear and dread when they encounter such sudden situations,which will affect the implementation of T-CPR: "In the process of T-CPR, sometimes it is necessary to calm the caller constantly.
In such a sudden situation, some callers are unstable and will be more anxious.
Sometimes on the phone we will tell them what to do and how to do, but they don't cooperate. They only ask you to send an ambulance as soon as possible.
They don't listen to the dispatcher at all. They don't understand why they need to rescue the sudden cardiac arrest (SCA) patients."(P7)

Theme two:Dispatching Factors
Dispatching factors were categorized into those that associated with lack of professional skills of dispatchers, dispatching equipment,and standard procedures of dispatch.

Factors associated with lack of professional skills of dispatchers
Because of the special nature of work, the particularity of working time, high recruitment requirements for recruiting, difficult promotion and low salary, the dispatchers are lacking and difficulty to recruit.Based on the difficulty of personnel identifying the first compression time and some parts of compression action after SCA (Dong et al.,2020;Plata et al.,2019).By installing guidance software in smartphones, it can provide guidance for the witnesses who are willing to perform chest compression.
It also can avoid the embarrassment that the publics are willing to implement CPR but not only lack official guidance but also lack legal support. Finally, the implementation rate of pre-hospital CPR for patients with cardiac arrest will be improved. This study also suggests that the coexistence of various guidance methods can promote the implementation of T-CPR. But no matter which guidance method, unified, simple, standardized flow chart is needed. It is very important to make the bystanders understand it and implement T-CPR in the first time.Using internet technologies to build smart pre-hospital emergency system may promote the implementation of T-CPR.
At present, the world is in the information era of vigorous development of big data, cloud computing, artificial intelligence and other frontier technologies. Internet technology is being deeply integrated with all walks of life. The internet information has also become an important measure to raise the level of pre-hospital rescue. The early diagnosis of SCA and early positioning of SCA patients may be achieved by building a smart pre-hospital emergency system. This study offers some new insights on it. For example, if the wechat, which is widely used in China, can send the specific positioning of the patients to the dispatching center at the first time and provide the bystanders guidance of audio, video and text of CPR, so that more SCA patients will be treated. Smart pre-hospital emergency system is also possible to achieve intelligent calculation of the best route, so as to minimize emergency response time, and gradually achieve 'accurate dispatch' and 'precise treatment'.
As this study shows that China has not yet enacted relevant laws at the national level to protect dispatchers from disputes encountered in telephone guidance. The dispatchers will have some misgivings because their rights and interests are fundamentally not guaranteed when they conduct telephone guidance. Previous studies by the research team also showed that a major concern of bystanders in implementing CPR is the lack of legal protection, especially when CPR is needed by the 'strangers' and 'acquaintances ' (Xuehua et al.,2013). Therefore, it is urgent for the relevant departments to promote the legislation of first aid exemption as soon as possible, to clarify the scope and content of first aid exemption, so as to encourage more people to help patients with cardiac arrest and avoid tragedy. In recent years, is more important than everything, and the value of life is paramount. We need to do more in first aid, which is also the most meaningful.

Limitations
Although this study adequately describes the experiences and opinions of some experts in the field of first aid in China, it is not without limitations.As with all qualitative research, the aim was to generate hypotheses and therefore lacks generalizability to all experts' experiences and views in all areas of emergency care in China.The researchers acknowledge that most of the selected research objects are from developed cities in China, and the sample size is small. Due to regional limitations, the sample representativeness will be affected, so it should be improved in future studies.The coding of this study was conducted by one researcher, which presents both benefits and potential bias. Future studies could employ multiple coders to analyze interview content.

Conclusion
In order to save SCA patients more effectively, urge bystanders to implement