Skip to main content

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study



T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival.


To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan.


A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant.


There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.).


Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Peer Review reports


It has been widely reported and accepted that rapid initiation of cardiopulmonary resuscitation (CPR) benefits the overall survival of patients with out-of-hospital cardiac arrest (OHCA).[1,2,3]. To get a successful resuscitation of OHCA victims, the American Heart Association (AHA) has endorsed the “Chain of Survival” as a framework [4]. The first link of the “Chain” is immediate recognition of cardiac arrest and early bystander cardiopulmonary resuscitation [BCPR]) of good quality with minimum interruption are strongly associated with improved survival in such patients.[5, 6]. The time between an emergency call and the arrival of emergency medical services (EMS) is one of the most critical time intervals for the outcomes of patients with OHCA. An attempt of cardiopulmonary resuscitation administered by a family member, a friend, or a nearby person in the community before emergency medical services, is called bystander cardiopulmonary resuscitation (BCPR). [7, 8]. It has been observed that BCPR is provided in only one-third to one-half of cases in most communities, despite this intervention being more than double the chance of survival in OHCA patients. [9]. However, the quality of BCPR is often poor, and overall, the number of patients receiving CPR is still very low. [10]

Telephone CPR (T-CPR) is a technique that provides instructions to callers of suspected OHCA cases about how to deliver compression and ventilation. Since this intervention holds enormous potential to increase bystander response to performing CPR and thus survival from cardiac arrest, T-CPR has been recognized as an integral component of an emergency medical system response to OHCA.[11]. In T-CPR, instructions were given verbally by telephone to a suspected case of cardiac arrest victim to increase the number of patients receiving CPR and improve the quality of CPR delivered [12]. However, bystanders often face multiple barriers to performing CPR, causing a delay in CPR initiation, and compromising the quality of CPR being provided[13]. Nevertheless, a study supported the positive impact of this intervention with a continuous quality improvement project as reported by the Ishikawa Medical Control Council in 2007, where they found a substantial decrease in the incidence of failed telephone CPR due to human factors with a drastically increased in bystander CPR through this intervention[14].

In India, a study was conducted to determine the acceptability of T-CPR. They found that in 599 cases of out-of-hospital cardiac arrest victims, instructions to perform CPR were given to the bystanders, and in the majority of cases, 482 (80%) CPR was not performed. In only, 117, (20%) cases CPR was attempted[15]. There is limited data on the use of TCPR in developing countries like Pakistan, especially little is known about the acceptability of TCPR amongst bystanders in our setting. The primary objective of this study was to evaluate the acceptability of T-CPR by the bystanders, and the secondary objective was to identify baseline quality measures of T-CPR in Karachi, Pakistan.

Operational definition

Acceptability of T-CPR

Acceptability of T-CPR was defined as performing CPR by bystander upon instructions provided by a telecommunicator [16] .


Study design and setting: We conducted a cross-sectional study and included all adults who met the criteria of Medical Priority Dispatch System (MDPS) code 9 & 31 and MPDS priority system code 3 [17] from January 2018 to December 2018.

Study setting

The study was conducted in Karachi, the largest city in Pakistan, with Several private, not-for-profit ambulance services serving the city. In Karachi, the public does not have one standard telephone number for a medical emergency and must call specific ambulance services. One of the major ambulance service providers is Aman Ambulance (more recently called Sindh Emergency Health and Rescue services), which provides advanced ambulance service with trained nurse paramedics. The ambulance call center has trained emergency medical telecommunicators who provide T-CPR. As far as we know, Aman Ambulance is the only service in Pakistan providing T-CPR.

Study procedure and data collection

We collaborated with Aman Ambulance service and obtained recordings of all telephone calls on which T-CPR instruction was provided. Hands-only CPR was performed. The research assistant (RA) trained for this study collected data from audio calls. We developed a questionnaire to collect data on age, gender, time to recognize the need for CPR, time to CPR instructions, time to initiation of BCPR, time of ambulance arrival, and barriers to performing CPR. Minor modifications were made to the structure of some questions after pre-testing with 40 participants. We included those patients on whom T-CPR instructions were provided by telecommunicator. To protect the privacy of the study participants, each person was given a unique study ID which was noted on top of the survey questionnaire.


Mean and Standard Deviation (SD) were calculated for continuous variables such as age, time to recognize the need for CPR, time to start CPR instruction, and time to start chest compression. Normality was checked through Shapiro–wilk test. Frequency and percentages were calculated for qualitative variables such as gender, scene of the event, and place of the event. We compared our results with the American Heart Association guidelines for T-CPR since they are applied in Pakistan. AHA divides its recommendation into the high-performance target and the minimum expected target. A One-way ANOVA was used to compare different time variables with recommended standards.


A total of 481 audiotaped calls in which CPR instruction was reviewed. Most OHCA occurred at home (89.3%; n = 430). Most of the bystanders started CPR when instructed by the telecommunicators. (95.4%; n = 459). 57.8% (n = 278) of patients on which CPR was performed were male.(See Table 1).

Table 1 General descriptive variables of the study

The mean time to recognize the need for CPR by a telecommunicator was 4:59 ± 1:59(minutes), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.) (See Table 2).

Table 2 Measures of time for T-CPR

Compared to the AHA timeline recommendations, they have divided into the high-performance system and minimal acceptable. In 3 (0.6%) of cases, the time to recognize the need for CPR was less than a minute, and in 28(5.8%) of patients, it was less than 2 min, while 440(93.5%) cases were beyond this timeline. In only 1(0.2%) of cases, CPR instruction was started within a minute, and in 14(3%) of patients, it was within 2 min, but in 453(96.8%) of cases, it was beyond that timeline. From time to the first compression, none met a high-performance system, and in 40(8.7%) cases, it was started within 3 min, meeting a minimal acceptable limit, while the rest was out of range. (See Table 3).

Table 3 Comparison of different time variants with recommended AHA guidelines


We aimed to assess the acceptability of T-CPR by the bystanders and measure baseline quality indicators for the T-CPR in Karachi, Pakistan. The study result showed that in more than ninety percent of cases, CPR was attempted after instructions provided on the phone.

A study reported that the most predominant barriers against telecommunicator-assisted CPR are emotional factors, including panic and hysteria [18]. McCormack AP also reported that willingness to perform CPR by a bystander might be affected by the patient's physical characteristics and its surrounding, such as vomiting were observed in 59% of cases had a negative impact on performing CPR [19]. Other studies also observed that, in a public place, an AED pad application or receiving bystander CPR for female OHCA patients was less difficult, especially in their reproductive age group.[20,21,22]. This could be possibly due to the cultural and social differences in different parts of the world.

We found a high level of willingness to perform CPR. This could be due to victims being known to the bystanders since most OHCA occurred at home. In a study by Birkun et al., about 79% of bystanders were willing to perform CPR on unknown people, and 91% were willing to attempt CPR on their friend or relative [23]. However, a study conducted in India in 2017 by Jyothi showed that 80% of the bystanders did not do CPR despite the telephonic instructions being given. [15]

We also noticed in our study that the majority of the bystander who performed CPR were females. This could be because women were more likely to be at home than their male partners. Although we did not collect the data on whether those bystanders who perform CPR had previous knowledge of it or had any formal training to perform CPR, it has been proven that if a person has received CPR training within the last five years or they have trained in their high school education will more likely willing to perform bystander CPR [24, 25].

We also assessed the baseline quality measures of CPR in the current situation and compared them with the AHA recommendations. We found significant delays in time (5 min) to recognize the need for CPR, with more than 90% being delayed beyond the range recommended by the AHA.,. In a study by Stangenes et al., the median time interval for recognizing T-CPR was 47 s. for valid medical complaints, and it took 100 s for false medical complaints[26]. Another study by Demi et al. reported a median time to recognize the need for CPR of 60 s [27]. Possible reasons for the delay in recognition of the need for CPR could be since most of them out of hospital cardiac arrest (OHCA) happen at home, allowing only a limited number of people to respond. Also, there is a lack of awareness in our world that doesn’t enable the bystanders to recognize the situation and the need for CPR immediately. [5]

The mean time to start the CPR instructions was also more than 5 min, which should ideally be less than 2 min; about 96.8% of cases were out of range. Similar findings were found in a study by Lewis et al. where they found a delay in CPR instruction by more than five seconds in 92.9% of cases. A proportion of the delays could be attributed to the telecommunicator asking superfluous incident and medical history questions after establishing that the patient was unconscious and not breathing[28]. The high mean time for the telecommunicators to start giving the instructions could be because OHCA is usually a panicky situation, [8] the family members or other bystanders cannot communicate effectively, let alone the delayed recognition, as a layperson. Our study also shows the delay at the telecommunicator’s side.

The mean time to start the first chest compression took 6 min, twice the recommended range (minimal acceptable < 3 min). A study by Hardeland in a developed country showed differences in the timings from that of our population. Their median time (mm: ss) to first chest compression was 02:35 (Copenhagen), 03:50 (Stockholm), and 02:58 (Oslo). [29].

The importance of this intervention was also highlighted in a study by Eisenberg et al., where they found that OHCA survival to discharge jumped from 6 to 21%, and the rates of bystander CPR were also increased from 32 to 55% after they implemented a dispatch-assisted CPR program in their EMS. Hence due to early recognition and prompt actions of their telecommunicators. King County report one of the world's highest cardiac arrest survival rates [30] A Dutch study CPR was not associated with ROSC or 30-day survival. Dispatcher-assisted CPR was especially beneficial for initiating bystander CPR in residential areas [31].

Our study highlights several areas of potential improvement. First, improved training and quality can considerably improve the time to recognize the need for CPR and the quality of instructions. Secondly, effective and timely CPR can be achieved when a considerable percentage of the population is trained in CPR through a national program targeted at the formal and informal schooling system. The training should involve both men and women in society to improve effective BCPR at home and outside.

Limited EMS facilities in the country, lack of centralized EMS, and their routine T-CPR training are concerns that need to be addressed. [15, 32]. In a study by Hasan et al., a DACPR implementation positively impacted the Kuwait EMS system; after DACPR implementation, the OHCA recognition rate increased from 2 to 12.9%, CPR instruction rate increased from 0 to 10.4%. [33]. They also had a similar conclusion as that of our study that the lack of knowledge of CPR skills and training among bystanders in the community is why most OHCA patients in India do not get appropriate and timely CPR. [15].

Strength and Limitations

This is the first-ever study in Pakistan evaluating the acceptability of T-CPR in an LMIC. There are a few limitations to this study. First, this was a single EMS system study from one city in Pakistan and did not represent all EMS systems and providers in the country. Most EMS providers in Pakistan don’t offer TCPR. Secondly, we used one-time data based on the recordings as this was a cross-sectional study and did not have a follow-up. Thirdly, we did not collect information on the patient outcomes. Fourthly, we did not have any information on patients with cardiac arrests on which no DA CPR instructions were given; thus, we don’t know the percent of patients with cardiac arrest who received DA-CPR.


Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Availability of data and materials

The data will be available at the reasonable request to Dr. Fareed Ahmed, the corresponding author at



Telecommunicator-Assisted Cardiopulmonary Resuscitation


Emergency Management System


Out of Hospital Cardiac Arrest


Research Assistant


Telephone Cardiopulmonary Resuscitation


  1. Sekimoto M, Noguchi Y, Rahman M, Hira K, Fukui M, Enzan K, et al. Estimating the effect of bystander-initiated cardiopulmonary resuscitation in Japan. Resuscitation. 2001;50(2):153–60.

    Article  CAS  Google Scholar 

  2. Group S-KS. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. The Lancet. 2007;369(9565):920–6.

    Article  Google Scholar 

  3. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63–81.

    Article  Google Scholar 

  4. Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circ. 2010;122(18_suppl_3):S676–84.

    Article  Google Scholar 

  5. Vaillancourt C, Stiell IG, Wells GA. Understanding and improving low bystander CPR rates: a systematic review of the literature. CJEM. 2008;10(1):51–65.

    Article  Google Scholar 

  6. McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, et al. Out-of-hospital cardiac arrest surveillance—cardiac arrest registry to enhance survival (CARES), United States, October 1, 2005–December 31, 2010. Morb Mortal Wkly Rep Recomm Rep. 2011;60(8):1–19.

    Google Scholar 

  7. Bagheri SMS, Sadeghi T, Kazemi M, Nadimi AE. Dispatcher-assisted bystander cardiopulmonary resuscitation (Telephone-CPR) and outcomes after out of hospital cardiac arrest. Bulletin of Emergency & Trauma. 2019;7(3):307.

    Article  Google Scholar 

  8. Shimamoto T, Kiyohara K, Matsuyama T, Kitamura T, Kiguchi T, Nishiyama C, et al. Impact of bystander cardiopulmonary resuscitation and dispatcher assistance on survival after out-of-hospital cardiac arrest among adult patients by location of arrest. Int Heart J. 2020;61(1):46–53.

    Article  Google Scholar 

  9. Bobrow BJ, Eisenberg MS, Panczyk M. The institute of medicine says time to act to improve cardiac arrest survival: here’s how. Ann Emerg Med. 2016;67(4):492–5.

    Article  Google Scholar 

  10. Lerjestam K, Willman A, Andersson I, Abelsson A. Enhancing the quality of CPR performed by laypeople. Australas J Paramedicine. 2018;15(4):590–94.

  11. Lerner EB, Rea TD, Bobrow BJ, Acker JE III, Berg RA, Brooks SC, et al. Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest: a scientific statement from the American heart association. Circ. 2012;125(4):648–55.

    Article  Google Scholar 

  12. Chen K-Y, Ko Y-C, Hsieh M-J, Chiang W-C, Ma MH-M. Interventions to improve the quality of bystander cardiopulmonary resuscitation: a systematic review. PLoS One. 2019;14(2):e0211792.

    Article  CAS  Google Scholar 

  13. Langlais BT, Panczyk M, Sutter J, Fukushima H, Wu Z, Iwami T, et al. Barriers to patient positioning for telephone cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017;115:163–8.

    Article  Google Scholar 

  14. Tanaka Y, Taniguchi J, Wato Y, Yoshida Y, Inaba H. The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests. Resuscitation. 2012;83(10):1235–41.

    Article  Google Scholar 

  15. Venkatesan J, Janumpally R, Gimkala A, Megavaran V, Myklebust H, Ramana Rao GV. Importance of “Telephone Cardiopulmonary Resuscitation” in out-of-Hospital Cardiac Arrest in India. Indian J Community Med. 2020;45(2):194–8.

    Article  Google Scholar 

  16. Moriwaki Y, Tahara Y, Kosuge T, Suzuki N. The effect of telephone advice on cardiopulmonary resuscitation (CPR) on the rate of bystander CPR in out-of-hospital cardiopulmonary arrest in a typical urban area. Hong Kong Journal of Emergency Medicine. 2016;23(4):220–6.

    Article  Google Scholar 

  17. Yousuf P, Hassan AM, Yaqoob U, Hatami N. Prehospital Emergency Services- Establishment and Expansion of Sindh Emergency and Rescue Services-1021 In A Metropolitan City of Pakistan. Updates in Emergency Medicine. 2021;1(1):2–9.

    Google Scholar 

  18. Case R, Cartledge S, Siedenburg J, Smith K, Straney L, Barger B, et al. Identifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: a qualitative review of emergency calls. Resuscitation. 2018;129:43–7.

    Article  Google Scholar 

  19. McCormack AP, Damon SK, Eisenberg MS. Disagreeable physical characteristics affecting bystander CPR. Ann Emerg Med. 1989;18(3):283–5.

    Article  CAS  Google Scholar 

  20. Blewer AL, McGovern SK, Schmicker RH, May S, Morrison LJ, Aufderheide TP, et al. Gender disparities among adult recipients of bystander cardiopulmonary resuscitation in the public. Circ Cardiovasc Qual Outcomes. 2018;11(8):e004710.

    Article  Google Scholar 

  21. Matsuyama T, Okubo M, Kiyohara K, Kiguchi T, Kobayashi D, Nishiyama C, et al. Sex-based disparities in receiving bystander cardiopulmonary resuscitation by location of cardiac arrest in Japan. Mayo Clin Proc. 2019;94(4);577–87.

  22. Matsui S, Kitamura T, Kiyohara K, Sado J, Ayusawa M, Nitta M, et al. Sex disparities in receipt of bystander interventions for students who experienced cardiac arrest in Japan. JAMA network open. 2019;2(5):e195111–e.

    Article  Google Scholar 

  23. Birkun A, Kosova Y. Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea. World J Emerg Med. 2018;9(4):237.

    Article  Google Scholar 

  24. Tanigawa K, Iwami T, Nishiyama C, Nonogi H, Kawamura T. Are trained individuals more likely to perform bystander CPR? An observational study Resuscitation. 2011;82(5):523–8.

    PubMed  Google Scholar 

  25. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med. 2006;13(6):596–601.

    Article  Google Scholar 

  26. Stangenes SR, Painter IS, Rea TD, Meischke H. Delays in recognition of the need for telephone-assisted CPR due to caller descriptions of chief complaint. Resuscitation. 2020;149:82–6.

    Article  Google Scholar 

  27. Dami F, Heymann E, Pasquier M, Fuchs V, Carron P-N, Hugli O. Time to identify cardiac arrest and provide dispatch-assisted cardio-pulmonary resuscitation in a criteria-based dispatch system. Resuscitation. 2015;97:27–33.

    Article  Google Scholar 

  28. Lewis M, Stubbs BA, Eisenberg MS. Dispatcher-assisted cardiopulmonary resuscitation: time to identify cardiac arrest and deliver chest compression instructions. Circ. 2013;128(14):1522–30.

    Article  Google Scholar 

  29. Hardeland C, Claesson A, Blom MT, Blomberg SNF, Folke F, Hollenberg J, et al. Description of call handling in emergency medical dispatch centres in Scandinavia: recognition of out-of-hospital cardiac arrests and dispatcher-assisted CPR. Scand J Trauma Resusc Emerg Med. 2021;29(1):88.

    Article  Google Scholar 

  30. Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circ. 2001;104(21):2513–6.

    Article  CAS  Google Scholar 

  31. Viereck S, Møller TP, Ersbøll AK, Folke F, Lippert F. Effect of bystander CPR initiation prior to the emergency call on ROSC and 30 day survival—an evaluation of 548 emergency calls. Resuscitation. 2017;111:55–61.

    Article  Google Scholar 

  32. Maier M, Luger M, Baubin M. Telephone-assisted CPR: a literature review. Notf Rett Med. 2016;19(6):468–72.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Al Hasan D, Drennan J, Monger E, Al Mahmid S, Ahmad H, Ameen M, et al. Dispatcher assisted cardiopulmonary resuscitation implementation in Kuwait: A before and after study examining the impact on outcomes of out of hospital cardiac arrest victims. Medicine. 2019;98(44).

Download references


This study was supported by The Pan-Asian Resuscitation Outcomes Study (PAROS).

Author information

Authors and Affiliations



FA, NK & UK - Conceptualization and Writing, Reviewing, & Editing. JR—Supervision. SS -Writing, Reviewing, and Editing. RN & AN- Data Curation. SS & AR- Data Analysis. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Fareed Ahmed.

Ethics declarations

Ethics approval and consent to participate

This research have been performed in accordance with the Declaration of Helsinki and approval was obtained from the Aga Khan University Ethical Review Committee ERC-3361-EM-14. Informed written consent was taken from participants before the data collection.

Competing of interests

The authors declare no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ahmed, F., Khan, U.R., Soomar, S.M. et al. Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study. BMC Emerg Med 22, 139 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: