February 2024

In this VETgirl online veterinary continuing education blog, Amanda M. Shelby, RVTg, VTS (Anesthesia/Analgesia) reviews the role of Client Service Representatives (CSR) or Client Service Coordinators (CSC) during cardiopulmonary resuscitation (CPR). During CPR, we need “all hands on deck” and we want to make sure we are including all members of the veterinary care team in recommended CPR training… so you’ll all be fully prepared when you need to save a life!

CSRs in CPR: Involving the Whole Veterinary Care Team

By Amanda M. Shelby, RVTg, VTS (Anesthesia/Analgesia)

Return of spontaneous circulation (ROSC) and survival to hospital discharge rates after cardiopulmonary resuscitation are low in veterinary medicine compared to human medicine. The Reassessment Campaign on Veterinary Resuscitation (RECOVER) is an ongoing initiative that seeks to standardize a systematic approach to CPR with the hope of improved patient outcomes. To accomplish this, the RECOVER team set out to provide veterinary professionals with an evidence-based algorithm for resuscitation and veterinary care team training guidelines. Pause and ask yourself, who makes up the veterinary care team? Who are the ideal members involved in cardiopulmonary resuscitation (CPR)? These are valuable questions to consider, ensuring we are including all members of the veterinary care team in recommended CPR training.

The first evidence-based veterinary CPR guidelines were published in 2012 and are available as open-access articles with Part 7 offering the clinically relevant algorithm for CPR. While waiting for the next rendition of RECOVER CPR guidelines (coming soon!), it is important to recognize successful execution of CPR comes from rapid identification of cardiopulmonary arrest (CPA) and implementation of CPR. This need for rapid recognition of a patient in distress or CPA is where a veterinary client service representative (CSR) can be an effective member of the veterinary care team in performing CPR.

Key to effective CPR outcomes is:

        • Rapid recognition of CPA or patient in distress
        • Rapid implementation of CPR

The CSR is often the first member of the veterinary care team to place their eyes on the patient arriving at the veterinary hospital. Depending on the veterinary hospital’s workflow process, the CSR could find themselves actively involved in CPR efforts. Current recommendations in veterinary medicine include refresher training for all members of the veterinary care team every three to six months.(1) Rapid recognition of CPA, and immediate initiation of quality basic life support (BLS) is associated with faster return of spontaneous circulation and improved survival rates.(2) BLS is defined as the period during CPR that includes recognition of CPA, facilitation of airway management, ventilation, and chest compressions.(3) In line with the key principles that could improve outcome, prioritization of training should take into account those members of the veterinary care team who first visualize the patient. Focus of training for the CSR should be to recognize common signs of distress in species the veterinary hospital serves, expedite access to members of the veterinary care team trained in performing BLS and advanced life support (ALS) of CPR and initiating the conversation with the pet owner regarding desired CPR directives for their pet.

Recognizing Signs of Small Animal Patient Distress and CPA
Training non-clinical health care team members to recognize patient distress and CPA is not novel. In human medicine, emergency room facilities that train and utilize non-clinical staff to assist in patient identification of triage urgency have demonstrated a 45% decrease in deaths since implementing training for non-clinical staff, including receptionists.(4) For veterinary clinics, training the CSR in recognizing signs of distress (Table 1) in commonly seen species for the purpose of identifying triage urgency and reviewing possible communications with clients (Table 2) can expedite the delivery of care by trained veterinary personnel. In an emergency hospital setting, CSR training should also include recognition and prioritization of triage assignments such as young puppies experiencing vomiting and diarrhea or kittens experiencing upper respiratory symptoms; these patients should be placed in ‘infectious’ examinations rooms and be seen quicker than more stable cases.

Table 1. Signs for small animal patient distress and CPA

  • Unresponsiveness
  • Dull mentation
  • Absent chest excursions, absent breathing
  • Absent palpable pulses/absent heartbeat
  • Uncontrolled bleeding
  • Seizure
  • Excessive respiratory effort
  • Open mouth breathing, panting in cats, rabbits, small mammals, and birds

Effective Communicators Take Training
Once the CSR recognizes a patient in distress, the veterinarian or veterinary technician should be immediately notified. The CSR should be trained to effectively manage the pet owner experiencing emotional distress. Effective use of the CSR should include initiating a conversation with the pet owner.

This conversation should describe the need for their pet to be seen by trained veterinary professionals quickly, and include a discussion of whether they would they like CPR to be performed on their pet should a CPA occur. The CSR should understand and be able to explain to pet owners that the survival to discharge rate for veterinary species is low but the best chance for survival is avoiding delay in starting CPR. The CSR should also be able to navigate the challenging conversation that CPR is associated with a financial commitment. While obtaining the pet owners agreement for the cost of their pet receiving this emergency care, the CSR should obtain the referring veterinarian’s contact information, patient records, if appropriate, and a brief description of what happened in the moments leading up to the patient’s CPA. An effectively trained CSR can collect this information in the brief period between patient presentation and the arrival of trained veterinary professionals that will provide resuscitative efforts. Providing CSR veterinary care team members with communication training is paramount for optimizing client experience and can affect patient outcomes. While literature does not specifically identify the impact of the CSR on CPR outcomes, there is evidence in human medicine that training in non-technical skills such as effective communication improves patient outcomes.(5) Furthermore, the implementation of communication skills training in veterinary practice can improve the quality of care in veterinary patients.(6) The team participating in this study identified the greatest outcomes as “enhanced teamwork, professional satisfaction, positive work environment, and long and lasting relationships with their clients.”(6) Table 2 provides suggested communications for CSRs in veterinary emergency situations.

Table 2

Effective Utilization of the CSR as Part of the Veterinary Care Team
Effective utilization of all members of the veterinary care team, including the CSR, improves client sustainability, which translates to improved hospital revenue, team member utilization, job satisfaction, and work-place culture. While not the primary target population of the 2023 AAHA Technician Utilization Guidelines, utilization of the CSR is highlighted to perform initial assessment for emergency situations by obtaining “initial information, reason for visit, and previous medical records.”(7) Figure 1 provides suggestions for utilization of the CSR as it relates to the pet owner and the veterinary healthcare team members actively providing CPR. Perhaps, future reporting of veterinary CPR outcomes will expand to include the impact of both medical and non-medical participants, as well as their respective roles in CPR efforts.

Distribution of duties veterinary care team CPR VETgirl blog

Figure 1. Distribution of duties for the veterinary care team during CPR

References:
1. Fletcher DJ, Boller M, Brainard BM, Haskins SC, Hopper K, McMichael MA, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. Journal of Veterinary Emergency and Critical Care. 2012;22(s1):S102-S31.
2. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation: Cardiovascular Quality and Outcomes. 2010;3(1):63-81.
3. Hopper K, Epstein SE, Fletcher DJ, Boller M, Authors RBLSDW. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 3: basic life support. Journal of Veterinary Emergency and Critical Care. 2012;22(s1):S26-S43.
4. Dekker-Boersema J, Hector J, Jefferys LF, Binamo C, Camilo D, Muganga G, et al. Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. African Journal of Emergency Medicine. 2019;9(4):172-6.
5. Boet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Canadian Journal of Anaesthesia. 2014;61(6):571.
6. Shaw JR, Barley GE, Hill AE, Larson S, Roter DL. Communication skills education onsite in a veterinary practice. Patient Education and Counseling. 2010;80(3):337-44.
7. Prendergast H, Mages A, Rauscher CJ, Roth LC, Thompson M, et al. 2023 AAHA Technician Utilization Guidelines.

Please note the opinions in this blog are the expressed opinion of the author(s)/sponsor, and not directly endorsed by VETgirl.

  3. Emily Freiermuth says:

    This was a nice quick way to get points across without being rude and abrupt with client, where the high stress situations are scary to the staff and clients expecting to treat these animals the best we can.

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