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Implementing a standard internal telephone number 2222 for cardiac arrest calls in all hospitals in Europe

      Background

      It is estimated that there are over 300,000 in-hospital cardiac arrests every year in Europe [
      • Nolan J.P.
      • Soar J.
      • Smith G.B.
      • Gwinnutt C.
      • Parrott F.
      • Power S.
      • Harrison D.A.
      • Nixon E.
      • Rowan K.
      • Bingham R.
      • Cummin V.
      • Gwinnutt C.
      • Lloyd-Scott L.
      • Maconochie I.
      • Mitchell S.
      • Nolan J.
      • Rowan K.
      • Smith G.
      • Soar J.
      • Spearpoint K.
      National Cardiac Arrest Audit
      Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.
      ]. Most European hospitals now have resuscitation teams and in-hospital cardiac arrest survival depends mainly on the effectiveness of the emergency response. Delays in the arrival of the resuscitation team are associated with reduced survival [
      • Sandroni C.
      • Ferro G.
      • Santangelo S.
      • Tortora F.
      • Mistura L.
      • Cavallaro F.
      • Caricato A.
      • Antonelli M.
      In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response.
      ]. In one study patient survival in the wards was significantly higher when the resuscitation team arrived within 3 min and there were no survivors when the team arrived after 6 min. Arrival time of the resuscitation team was significantly shorter (1.30 min ± 1.70) in survivors than in non-survivors (2.51 min ± 2.37; P< 0.005)

      Evidence

      It is thought about 80% of European hospitals use a telephone system to call the resuscitation team and there is a wide variety of different telephone numbers used. One survey showed 105 different numbers used by about 200 hospitals in Europe [

      A standard Cardiac Arrest Call –2222, ESA Newsletter, Issue 65, 2016 http://newsletter.esahq.org/a-standard-cardiac-arrest-call-2222/ (Accessed 6 February 2017).

      ]. A whole variety of non – standardised numbers was used e.g. 4271, 53, 111, 8686 but the commonest was 2222. A survey in Denmark provided evidence that just 50% the medical staff knew the correct number to call in their own hospital [
      • Løfgren B.
      • Larsen C.B.
      • Rasmussen M.L.
      • Henriksen F.L.
      • Krarup N.H.
      Limited knowledge of the crash call number among hospital staff—a call for standardisation.
      ]. One reason for delay in arrival of the resuscitation team is staff not knowing the number to call and in another survey 12% of staff said they only found out the number during an arrest [
      • Panesar S.S.
      • Ignatowicz A.M.
      • Donaldson L.J.
      Errors in the management of cardiac arrests: an observational study of patient safety incidents in England.
      ].
      Standardising the cardiac arrest telephone number improves staff awareness [
      • Whitaker D.K.
      Reply to letter: a call for 2222 in European hospitals.
      ]. In a personal survey that was undertaken in a hospital in Manchester, where the national standard number 2222 has been in use since 2004, 96% of 50 staff questioned knew the resuscitation number. This reflects the ease with which a national standard number can be remembered. Similarly in a recent survey from Denmark more of the physicians from a region that used a standard cardiac arrest number could remember that number compared with physicians interviewed from other regions. (78% v 33%, p < 0.001, chi squared test) [
      • Lauridsen Kasper Glerup
      • Løfgren Bo
      A call for 2222 in European hospitals—A reply to letter by Dr. Whitaker.
      ].
      Standardisation makes it easy for people to always do the right thing, reduces variation and assists in error proofing processes in healthcare [
      • Croteau R.J.
      • Schyve P.M.
      Chapter 10, proactively error-proofing health care processes.
      ].
      Martin Bromiley, Chair of the Clinical Human Factors Group (CHFG) says “Standardisation has been shown to be an effective mechanism for reducing human error in complex processes or situations. The CHFG fully supports this Patient Safety initiative and encourages all European Hospitals to standardise their ‘Cardiac Arrest Call’ telephone number [

      European Standardisation of the in-hospital ‘Cardiac Arrest Call’ Number 2222. Joint press release by the European Resuscitation Council, the European Board of Anaesthesiology and the European Society of Anaesthesiology 22nd September 2016. https://www.esahq.org/∼/media/ESA/Files/Resources/Cardiac%20Arrest/Joint%20Press%20release%202222%2020-9-2016%20v6.ashx (Accessed 6 February 2017).

      ].
      Standardisation is a fundamental principle of safety and in a review of standardisation in patient safety: in connection with the WHO High 5s project the authors stated ‘The standardisation of hospital processes should enable trained health care workers to perform effectively in any facility in the world’ [
      • Leotsakos A.
      • Zheng H.
      • Croteau R.
      • Loeb J.M.
      • Sherman H.
      • Hoffman C.
      • Morganstein L.
      • O′Leary D.
      • Bruneau C.
      • Lee P.
      • Duguid M.
      • Thomeczek C.
      • van der Schrieck-De Loos E.
      • Munier B.
      Standardization in patient safety: the WHO High 5s project.
      ]. They drew an analogy to the level of standardisation in the airline industry. A pilot trained to fly an Airbus A320 can fly an Airbus A320 belonging to any airline company in any country. So why not arrange for every European healthcare worker to learn one standardised telephone number 2222 to call the resuscitation team in any hospital, in any country in Europe.
      Nurses make most of the telephone calls to summon the resuscitation teams in hospital and they also increasingly move jobs between different hospitals and also different countries. In Spain in 2007 one in five nurses entering the nursing workforce was foreign-trained or a foreign-national and this reached one in three in Italy in 2008 [
      ]. Calls for national standardisation of the in-hospital cardiac arrest telephone number have been made for over 20 years [
      • Beshyah Salem A.
      • Schiff Rebekaf
      • Al-Jehani Fathi S.
      National crash call number is needed.
      ] and some countries have successfully standardised [

      Establishing a standard crash call telephone number in hospitals. Patient Safety Alert 01/2005.24 February 2004 http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59789 (Accessed 6 February 2017).

      ,
      Safety Action Notice. Establishing extensionnumber 2222 in Scotland as a standard cardiac arrest call in hospitals.
      ]. In September 2016 a joint press release from the European Resuscitation Council (ERC), European Board of Anaesthesiology (EBA) and the European Society of Anaesthesiology (ESA) recommended that all Hospitals in Europe standardise to the number 2222. Health ministers and employers have good cause to lower the administrative burden on healthcare staff and standardising to 2222 will also help achieve this. Every nursing, medical and other healthcare student could be taught the standard number at the beginning of their training.

      Implementation

      The arguments above are compelling but how can this be implemented? We suggest at least 3 possible ways: international, national and local.
      International regulation or legislation from central European authorities could be one potential way. Representations are being made at this level but the process can take many years; it took 17 years to get an EU directorate to standardise the external emergency telephone number to 112 in Europe [

      Directive 2009/136/EC of the European Parliament and of the Council of 25 November 2009 eur-lex.europa.edu. 25 November 2009. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:2002L0022:20091219:EN:PDF (Accessed 6 February 2017).

      ].
      National professional bodies can recommend to their members and national Health Ministers to promote the 2222 initiative and many are starting to do this. The DGAI in Germany has taken the lead in this and already contacted their Health Minister, Herman Gröhe. He supported the initiative and on 24th January 2017 wrote to the Federation of German Hospitals to recommend it.
      Local action within hospitals; it appears that many of the hospitals’ original cardiac arrest call numbers were chosen sporadically, often appearing random and unmemorable [

      A standard Cardiac Arrest Call –2222, ESA Newsletter, Issue 65, 2016 http://newsletter.esahq.org/a-standard-cardiac-arrest-call-2222/ (Accessed 6 February 2017).

      ]. Logically therefore by the same local process in these hospitals doctors and other healthcare staff could request the change is made in their own place of work to follow the ERC, EBA and ESA recommendation as a local patient safety improvement project. In November 2016 some doctors in Slovakia did just that and agreed with their management to change to 2222. This was quickly and safely achieved at little cost and without problems [
      • Trenkler S.
      • Simonova J.
      • Grochova M.
      Implementing the standardised cardiac arrest call telephone number for all European hospitals –2222.
      ]. The old number and 2222 will operate in parallel for several months until all staff have stopped using the old number.

      Call for action

      Patients are familiar with the use of standardised emergency numbers in the public domain and if asked would probably be most surprised to discover that these hospital emergency numbers are not standardised already. For this and all the reasons above we would encourage everyone, doctors, nurses and managers to consider taking action in their own place of work and standardising the internal telephone number for cardiac arrest calls to 2222 as soon as possible.
      More information including a PowerPoint presentation to download and a local implementation pack for establishing a standard ‘Cardiac Arrest Call’ telephone number for all hospitals in Europe – 2222 can be found at: http://www.esahq.org/resources/resources/cardiac-arrest-call/

      Conflicts of interest

      DW – none declared.
      JN – Editor-in-Chief Resuscitation.
      MC – none declared.
      CA – none declared.
      ZG – Shareholder in a governmental supported start-up for collaboration between Christian; Muslim and Jewish Scientists based in Nazareth.

      References

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        In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response.
        Resuscitation. 2004; 62: 291-297
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