Before 2018, two alert systems supporting volunteering help during OHCA incidents were deployed in the Netherlands. One was provided by the company Stan, the other by a group of ambulance services. Both used the home or work address of the users to identify the users closest to the OHCA incident. The Stan solution also included the option to use GPS tracking from 2010 onwards, thus supporting a more accurate identification of the users closest to the incident. In 2018, the organisations decided to join and launch the national alert system HartslagNu. The organisations integrated their responders and AED databases, and they migrated to the Stan alerting technology.
This new system exploits newer smartphone’s location technology that enables a more accurate identification of the users closest to the incident.
HartslagNu is both the name of the system and of the foundation that provides it. The foundation consists of the Dutch Heart Foundation and two major ambulance groups. The Heart Foundation is responsible for promoting HartslagNu, for recruiting civilian first responders and automated external defibrillators (AEDs). The technology is supplied by the company Stan. Stan also provides a helpdesk and manages the responders.
HartslagNu works together with the emergency services and the Regional Safety Regions. All dispatch centres in the Netherlands are connected to the HartslagNu system. The goal is to maintain a six-minutes zone for OHCA help throughout the Netherlands. More than 13.000 calls are handled by the system on a yearly basis.
The users of HartslagNu sign up with their identity, and their home or work address. They are asked to allow the app to use their GPS location. The home or work address is usd in case people don’t allow sharing the GPS location. When the emergency dispatch centres receive a call about a suspected OHCA, a push notification is sent to the 100 users closest to the incident location within a maximum range of 1.5 km. The notified users can decide to approve the request or not. Civilian first responders have two roles: the closest are responsible to start cardiopulmonary resuscitation (CPR), the others are directed to pick up an automated external defibrillator (AED).
To ensure the security of civilian first responders and to avoid traumatic experiences, some critical situations, such as criminal cases, drowning or car accidents, are automatically or manually filtered out by the dispatch centres.
The civilian first responders are required to have trained CPR and AED during the last two years. The users are required to provide a proof of training during subscription. After that the system checks the dates and runs the admin. 3 months ahead of the expiration period, users receive a notification through the app. In practice, there is no actual verification of the course certification provided by the user in The Netherlands. There were no major issues with civilian first responders. Verification could be done if desired by an organisation.
The software is also used in Lithuania. The experience from the implementation and use in that country is not covered here.
Recruiting civilian first responders requires focused campaigns, in particular in the launch phase of the solution. Keeping track of areas with few responders and collaborating with local authorities in these areas can facilitate recruiting more people in these areas.
Citizens should understand the risk related to heat arrests to be willing to join as civilian first responders.
Civilian first responders should preferably have CPR training.
Knowledge about CPR and AED is important. Making CPR training easily available can contribute to more volunteers. Digital literacy is also essential as the system is app-based.
The implementation of the solution requires a solid infrastructure including software, AEDs and a registry of AEDs. The software has to be integrated with the dispatch centre system. The number of AEDs and the coverage are important. The costs of establishing and maintaining this infrastructure as well as those of promoting the solution are non-negligeable.
The implementation and promotion of the system requires a good collaboration between various stakeholders such as national and local health authorities, emergency services, CPR training providers, and AED providers.
The civilian first responders close to the incident location can provide help quickly before the arrival of the ambulance. The number of responders to be notified and the size of the area should be configured based on experience.
Maintaining knowledge about CPR is useful when providing help.
There are fewer civilian first responders in rural areas than in urban areas, but the acceptance rate is higher in rural areas than in urban areas.
The system should be adapted and strengthened based on experience. The number of qualified persons in the country, the number and coverage of volunteers, their willingness to accept an alert, the number and coverage of AEDs, the response times are important data that should support effective planning.
Planning resources to follow-up the civilian first responders after an incident is important.
At the exception of critical situations, the solution is used when emergency services receive an emergency call that is classified as OHCA. Experience has shown that around 1 out 18 accepts the request to provide help with an acceptance rate higher in a radius of 100-200 meters. By 2023, there are around 230 000 of users in The Netherlands (for a total population of 18M). In 2022, civilian first responders were found in 100% of the incidents, in 82,6% a civilian first responder accepted the alert, and in 64,7% of the cases an AED was also retrieved. CPR was started by a civilian first responder in 69,2% of the incidents. The research from the Arrest group at the Amsterdam UMC finds that the introduction of the app has increased the survival rate for OHCA from 26% to 39% in residential areas.
The helpdesk follows up the civilian first responders to ensure their well-being after an incident.
Location tracking makes the battery drain faster. Therefor platforms providers set restrictions on how long apps can make use of tracking. Users have to reactivate the GPS tracking regularly. The HartslagNu app sends a reminder to users to do so.
It is harder to recruit people in rural areas. However, the acceptance rate is higher in rural areas than in urban areas. The foundation HartslagNu works with municipalities to recruit more people in rural areas.
Few users respond to notifications during night time.
Some users never log in the system. It is important to check user accounts regularly. Inactive users are notified and removed if not responding. For example, 30 000 accounts were newly removed (in 2023). The cleaning of data prevents from sending notifications to inactive users and lead to a higher acceptance rate.
As the system relies on the emergency to be called, non-witnessed incidents do not receive the professional or civilian response needed. New development is currently being done in order to identify these kinds of incidents. The approach is based on receiving an alarm from smart devices. Another benefit of the automatic approach would be to reduce the overall response time, also for witnessed incidents. It is estimated that the response time can be reduced by 1-2 minutes, by skipping the time currently needed to go through the triage protocol. There are however also foreseen challenges in the case of non-witnessed incidents, for example meeting a close door or false positives.