Delay of emergency calls is a preventable human factor which is associated with poor OHCA outcomes
[7, 8, 18]. A majority of previous reports regarding education and public awareness of BLS investigate the effects of BLS education on citizens' awareness and willingness to perform bystander CPR
[24–26] and the quality of CPR
[27–29]. Therefore, to the best of our knowledge, this cross-over questionnaire survey is the first to assess the effects of BLS training on attitudes toward making early emergency calls and to compare two types of BLS training course that are classified by the number of rescuers present.
We analyzed factors associated with willingness to make early emergency calls by comparing responses to scenarios wherein help from others is easily available or multiple rescuers are present (Scenario-M questionnaire) with scenarios wherein help is unavailable (Scenario-S questionnaire). In univariate analysis shown in Figure
1, the willingness for Scenario-S questionnaire after training course was significantly higher in participants of Course-S than in those of Course-M (odds ratio 1.706, 95% confidential interval 1.301–2.237), suggesting that Course-S more efficiently augmented willingness than Course-M. Multiple logistic regression analyses of Scenario-M questionnaire responses indicated that while post-course respondents were associated with willingness, BLS course types (Course-M or Course-S) were not, suggesting that both types of BLS training course potentially augment willingness to make emergency calls in situations where multiple rescuers were present. Moreover, prior BLS training course experience within 3 years was an independent factor. In contrast, multiple logistic regression analysis of responses to the Scenario-S questionnaire revealed that post-course respondents and BLS single rescuer Course-S were independent factors associated with willingness and that prior BLS training experience was not. These results indicate that the standard BLS training course for multiple rescuers does not augment willingness to make early emergency calls when the respondent is a single rescuer. Furthermore, other independent factors associated with willingness to make early emergency calls were younger age, male gender, and employment status.
Most OHCAs occur in homes
[30, 31] at relatively isolated locations from the emergency medical service system, where emergency calls are frequently delayed
[9, 19] and multiple rescuers are rarely present
[18, 30]. Elderly family members have the highest probability of being a victim or a bystander of at-home OHCAs
[9, 30], and their cardiac arrests are most frequently witnessed or recognized by spouses and daughters
[32, 33]. The present study and our previous large questionnaire surveys
[34, 35] have indicated that elderly and female citizens were more reluctant to place early emergency calls, presumably because of emotional stress
[36, 37] and the large gender gap in Japan
. When these bystanders witness and recognize cardiac arrests as single bystanders or rescuers, high emotional stress leads to placement of the first call to reliable family members, relatives, friends or general practitioners
[9, 34, 35]. Further, bystanders more frequently initiate CPR in compliance with DA-CPR than on their own initiative
[10–13]. Therefore, during the training course-S for single rescuers, instructors emphasized the importance of making early emergency calls to get an advice from the dispatcher for resuscitation, although availability of DA-CPR was known to all participants in both training courses. It is likely that the BLS training course designed for single rescuers should be applied for elderly and female participants whose daily life is spent at home.
DA-CPR has been reported to increase the incidence of bystander CPR and is expected to improve the outcomes for individuals who experience OHCAs
. Strong recommendations for DA-CPR have been made by the International Liaison Committee on Resuscitation in their 2010 Consensus
 as well as in a scientific statement from the American Heart Association
. However, the benefits of DA-CPR for OHCA outcomes are diminished by delay of emergency calls, which consequently delays bystander CPR. In addition to emphasis on early emergency calls in all BLS training courses, application of BLS training for single rescuers may diminish the delay in placing an emergency call.
This study had several limitations. Two BLS courses (Course-M and Course-S) were performed in a cross-over manner in eight fire departments of the Ishikawa Prefecture. Multiple logistic regression analyses revealed that residential areas or locations of fire departments were not independent factors associated with willingness to make early emergency calls (Table
4). However, we did not evaluate the quality of BLS instructions. Moreover, although all instructors involved in this study were qualified staff adhering to standard instruction manuals, the quality of instruction may have affected the results of this study. Approximately half of the respondents were female. A majority of respondents were middle aged, were employed and had previous BLS training experience. Therefore, the results of this study may not reflect the willingness of elderly females, who are the most likely witnesses of cardiac arrests. Because of limitations of time, the questionnaire in this study was only designed to assess willingness to make early emergency calls. The willingness to perform other BLS actions, including CPR and use of automated external defibrillators, were not evaluated. The effects of two types of BLS training were evaluated by comparing answers to questionnaires administered before the BLS course with those administered immediately after the BLS course. Therefore, the duration of willingness to make early emergency calls remains unknown.