Standardisation of the ‘Cardiac Arrest Call’ telephone number 2222 (Whitaker)
When a patient has an in-hospital cardiac arrest the response time of the resuscitation team is critical to their survival. Commonly a member of staff will dial an internal telephone number to start the process of summoning the resuscitation team. Although in many countries, outside the hospital the general public have a standard number to call (e.g.112), inside hospitals a wide variety of different numbers is used. If all hospitals were to use the same standard number, for example, 2222, this would reduce the possibility of delays and provide other advantages as well. Some countries have already implemented 2222 as a standard national number and many organisations now recommend this simple low-cost patient safety initiative.
Many of the population in Europe and worldwide are aware of the single standard emergency number 112 which can be dialled as a free call from any telephone in Europe (https://ec.europa.eu/digital-single-market/en/eu-rules-112). If there is a cardiac arrest in the street, a call to this number will put them through to the local ambulance service who will attend as soon as possible to help with resuscitation of the patient (https://www.sos112.be/en/).
Inside hospitals in Europe however there are no similar standard emergency number. It is estimated there are about 300 000 cariac arrests in European hospitals every year and when one happens, in many hospitals a nurse or other member of staff will dial a telephone number to contact the operator at the hospital telephone switchboard.555 The answering of calls to this ‘cardiac arrest number’ is given priority by the operator who then invokes the appropriate emergency callouts of the medical and nursing members of hospital’s, cardiac arrest team. About 80% of European hospitals that have a cardiac arrest team use the telephone system in this way. Some other hospitals use red call buttons on the wall of the ward or the patient’s room but not all hospitals have cardiac arrest teams (ESA Newsletter, Issue 65, 2016 http://newsletter.esahq.org/a-standard-cardiac-arrest-call-2222/).
Patient survival depends on the effectiveness of the emergency team response and any delays in the team’s arrival, defibrillation or initiation of cardiopulmonary resuscitation (CPR) all seriously reduce survival, decreasing by 10% per minute.556 A recent study from the United States, ‘Get With The Guidelines-Resuscitation Database’ has confirmed that time to initiation of CPR and subsequent time to administration of defibrillation (for shockable arrhythmias) and epinephrine injection were both associated with reduced patient survival.557 Another study showed that survival was significantly higher when the resuscitation team arrived within 3 min: there were no survivors when the team arrived after 6 min.558
Evidence to support a standardised cardiac arrest call number
In 2016, a European wide survey conducted by the ESA showed that 105 different telephone numbers were used in about 200 hospitals for example, 4361, 19, 623, 80932 but the commonest was 2222: (Fig. 13). Additionally, respondents were asked if they thought this cardiac arrest number should be standardised in all hospitals: 81% thought that it should (ESA Newsletter, Issue 65, 2016 http://newsletter.esahq.org/a-standard-cardiac-arrest-call-2222/).
Previous national surveys revealed that in Denmark where there were 41 different numbers, Ireland 18, England and Wales 27 and Australia 51 (Table 21). Recently the Netherlands reported 46 different numbers from 121 hospitals, with 12% already using 2222, and Spain had 51 different numbers from 288 different hospitals. A survey in Japan showed 370 different numbers from 756 hospitals having a cardiac arrest system.
One reason for delay in the arrival of the cardiac arrest team is ward or other staff not knowing the correct number to call. A survey in Denmark showed that only 50% of medical staff and 58% of nursing staff knew the correct number to call in their own hospital.559 Another study noted that 12% of staff only found out the number during a cardiac arrest incident when they had to call it.560 Standardising the number improves staff knowledge and makes it easier for them to remember it. In a survey from Denmark more of the physicians from a region that used a standard cardiac arrest number could remember that number compared with physicians from other regions with nonstandardised numbers (78 vs. 33%, P < 0.001).561 In the United Kingdom where there has been a national standardised number 2222 since 2004, 96% of the staff knew the 2222 resuscitation number.562 From consideration of human factors it can be expected that in stressful situations it is likely that memory will be even poorer.
Nurses make most of these telephone calls and increasingly they move posts between different hospitals and also between different countries. In 2017 in Spain, one in five nurses entering the workforce was foreign trained or a foreign national and in 2018 in Italy this reached one in three.563
Standardisation is a fundamental principle of safety
The airline industry is well aware that standardisation is a fundamental principle of safety. Pilots trained to fly an Airbus A320 can fly an Airbus A320 belonging to any airline company in any country in the world. Leotsakos said that standardisation of hospital processes should enable trained healthcare workers to perform effectively in any facility in the world.564 Logically it should be possible to arrange for every healthcare worker to learn one standardised telephone number (2222) to call the cardiac arrest team in any hospital in any country in the world. 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 telephone number to 2222’. European Standardisation of the in-hospital ‘Cardiac Arrest Call’ number 2222. Joint press release by the European Resuscitation Council, the EBA and the ESA 22 September 2016 (https://www.esahq.org/uploads/media/ESA/Files/Resources/Cardiac%20Arrest/Joint%20Press%20release%202222%2020-9-2016%20v6.pdf).
Calls for national standardisation of the in-hospital cardiac arrest telephone number have been made since the 1990s and some countries have successfully standardised.565,566 In 2015, the EBA recommended that all European hospitals use 2222 for in-hospital cardiac arrest calls and in 2016 they were joined by the European Resucitation Council and the ESA who issued a joint statement recommending that all European hospitals use the same internal telephone number 2222 to summon help when a patient has a cardiac arrest.567 This was supported by the WFSA and the International Liaison Committee on Resuscitation.
Additional benefits of standardisation to 2222
Having a common standard number will facilitate and standardise teaching, and 2222 is particularly memorable. A standardised number helps overcome some human factor issues such as memory being less reliant during stressful situations, and will enable standardisation of documents. Standardisation will make staff more confident that they will remember the number and reduce the potential for staff to become second victims if their lack of knowledge of the number results in a delay which causes patient harm. Organisations demonstrating attention to standardisation helps raise the safety culture, and this helps to create multidisciplinary safety interactions between nurses, doctors and other hospital staff. Implementing standardisation for such a simple and logical thing sets a precedent for more difficult standardisation issues in the future and emphasises appreciation of standardisation.
Why was the number 2222 chosen?
Having the same number is much more important than the actual number itself and discussions about the actual digits could continue for a long time and delay implementation: 2222 was chosen because it was the commonest number in surveys (ESA Newsletter, Issue 65, 2016 http://newsletter.esahq.org/a-standard-cardiac-arrest-call-2222/).568 It is also easy to remember and find on the telephone. From surveys, most hospital switchboards now use four digits and 2222 was already a standard national number for some time in England, Wales, Scotland, Turkey, Ireland and regions of Denmark and Slovakia.569 If hospitals only have a three-digit switchboard they could standardise to 222 and then if a member of staff dialled four 2s by mistake the call will still go through.
Costs for hospitals to change to 2222
As patient safety interventions go, this standardisation would be described as a very low-cost intervention. When England and Wales standardised, 30 hospitals changed for no cost at all and 43 for less than £1000. The average cost for 105 hospitals was £4500.568 Recently the Chief Executive from Ramsay Healthcare in Australia reported a cost of only AU$250.
How to implement 2222
There appear to be three possible ways to implement this standardisation: international, national and local. International regulation or legislation would be a robust way of achieving standardisation, but it is usually a long process to achieve this. The EU directorate to standardise the public emergency telephone number to 112 in Europe took 17 years. National professional bodies can recommend 2222 to their members and Health Ministers can recommend 2222 nationally to hospitals. In 2017, the German Society for Anaesthesia and Intensive Care (DGAI) contacted the German Health Minister who supported this initiative and wrote to the Federation of German hospitals to recommend 2222 be adopted. Similarly, in April 2018 the Irish Health Service Executive wrote to all the acute hospitals in Ireland and asked them to establish 2222 as a standard cardiac arrest number by January 2019. In December 2018, the health minister of New South Wales Australia standardised the internal hospital emergency number as 2222 and Ramsay Healthcare with 70 private hospitals nationally are also adopting 2222. In October 2018, the Ministry of Health in Portugal issued a legal order requiring hospitals with cardiac arrest teams to use the standardised number 2222 from 31 March 2019. Similarly the Czech Republic and Israel standardised to 2222 in November and December 2019, respectively.
Examining the numbers from surveys it appears that many of the original numbers used were often chosen locally at random and there was no structured process involved. Therefore, logically by the same local process 2222 could be implemented in hospitals that choose to do so as a local patient safety improvement project. In 2016, in Slovakia a group of doctors and managers agreed to change to 2222 and quickly and safely achieved all this in 2 weeks with very little cost and with no problems.570 Changing the cardiac arrest number can be perfectly safe if the switchboard operates the old number in parallel with 2222 for say a year until all staff had stopped using the old number. Local implementation may also be helped by the European Resuscitation Council (ERC) recommendation of the number 2222 in the ERC Quality standards for cardiopulmonary resuscitation practice and training 2019 (https://www.erc.edu/sites/5714e77d5e615861f00f7d18/assets/5dedf6664c84860818e4d3c0/CPR_quality_standards_In_hosp_accute_ERC_V3_Final_1_.pdf).
Why would hospitals not want to change?
As discussed, the cost is very low, particularly when compared with most other safety interventions. Standardisation simplifies training with only one memorable number to be learnt whichever hospital one is working in. It has been demonstrated that the change can take place quickly. One region in Slovakia chose a changeover date and then implemented it in only 2 weeks, although it took a year for all of England and Wales to standardise the number. There should be no concern about the risk of changing because it is very safe if the hospital continues to use the old number along with 2222 until no one calls the old number. The easiest response is not to change at all, but this will send a negative signal about a lack of safety culture within that particular hospital and suggest that there is not an understanding of the value of standardisation for patient safety. The number 2222 may already be used for some other function within the hospital but in this case this number should be changed anyway because once widespread cardiac arrest call standardisation takes place this extension may be called by mistake when someone is trying to activate the cardiac arrest team. Many modern switchboards are now computerised and even five-digit or six-digit switchboards can still accept a four-digit 2222. Most technical switchboard problems that have been encountered have had solutions but if there are currently insurmountable technical problems with the particular switchboard then the change to 2222 can be delayed and specified for when the next switchboard upgrade or replacement takes place.
Standardisation of cardiac arrest call numbers in hospitals to 2222 is common sense and 14 countries have already demonstrated the change to 2222 can be a safe, easy, smooth and low-cost patient safety improvement. An action list is shown in Table 22. In low-income countries where cardiac arrest teams are not yet established, designating 2222 in advance as the number to be reserved and used in the future will imbed this patient safety initiative into their system from the outset.
If all healthcare staff use the same global number 2222 this will promote the message of global standardisation and the development of a global safety culture for the future. Once the benefit of this relatively simple global standardisation becomes apparent, it will make the implementation of others easier.
Practical advice on how to change is available from several links:
- (1) Local Implementation Pack for establishing a standard ‘Cardiac Arrest Call’ telephone number for all hospitals in Europe – 2222 (http://www.esahq.org/resources/resources/cardiac-arrest-call/).
- (2) Establishing a standard crash call number in hospitals. (https://www.resus.org.uk/archive/archived-cpr-information/standardisation-of-the-crash-call-number-2222/).
- (3) European Society of Anaesthesiologists (https://www.esahq.org/patient-safety/2222-cardiac-arrest-call/).
A website includes a world map (https://ishen.ushahidi.io/views/map) where hospitals can enter the particular cardiac arrest number they use and this can demonstrate the implementation of this patient safety initiative as it rolls out throughout the globe.
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