Special article
Recommendations in dispatcher-assisted bystander resuscitation from emergency call center
Recomendaciones para el soporte telefónico a la reanimación por testigos desde los centros de coordinación de urgencias y emergencias
J. García del Águilaa, J. López-Messab,
, F. Rosell-Ortiza, R. de Elías Hernándezc, M. Martínez del Valled, L. Sánchez-Santose, J. López-Hercef, M. Cerdà-Vilag, C.L. Roza-Alonsod, M. Bernardez-Oteroe, in representation of the Scientific Committee of the Spanish Cardiopulmonary Resuscitation Council (Consejo Español de Resucitación Cardiopulmonar, CERCP) , Investigators of the Out-of-Hospital Spanish Cardiac Arrest Registry (Registro Español de Parada Cardiaca Extra-Hospitalaria, OHSCAR) , the Spanish Pediatric and Neonatal Cardiopulmonary Resuscitation Group (Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal)
Corresponding author
a Empresa Pública de Emergencias Sanitarias (EPES) de Andalucía, Sevilla, Spain
b Servicio de Medicina Intensiva, Complejo Asistencial Universitario de Palencia, Palencia, Spain
c SAMUR-Protección Civil, Ayuntamiento de Madrid, Madrid, Spain
d Servicio de Asistencia Médica Urgente (SAMU-Asturias), Oviedo, Spain
e Fundacion Publica Urxencias Sanitarias de Galicia-061, A Coruña, Spain
f Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Madrid, Spain
g Consell Català de Ressuscitació, Barcelona, Spain
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"apellidos" => "Bernardez-Otero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 10 => array:1 [ "colaborador" => "in representation of the Scientific Committee of the Spanish Cardiopulmonary Resuscitation Council (<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Consejo Español de Resucitación Cardiopulmonar</span></span>, CERCP)" ] 11 => array:1 [ "colaborador" => "Investigators of the Out-of-Hospital Spanish Cardiac Arrest Registry (<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Registro Español de Parada Cardiaca Extra-Hospitalaria, OHSCAR</span></span>)" ] 12 => array:1 [ "colaborador" => "the Spanish Pediatric and Neonatal Cardiopulmonary Resuscitation Group (<span class="elsevierStyleItalic"><span class="elsevierStyleBold">Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal</span></span>)" ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Empresa Pública de Emergencias Sanitarias (EPES) de Andalucía, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Complejo Asistencial Universitario de Palencia, Palencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "SAMUR-Protección Civil, Ayuntamiento de Madrid, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Asistencia Médica Urgente (SAMU-Asturias), Oviedo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Fundacion Publica Urxencias Sanitarias de Galicia-061, A Coruña, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Consell Català de Ressuscitació, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para el soporte telefónico a la reanimación por testigos desde los centros de coordinación de urgencias y emergencias" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1384 "Ancho" => 995 "Tamanyo" => 299102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dispatch-assisted bystander cardiopulmonary resuscitation in children.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Out-of-hospital cardiac arrest (OHCA) is a public health problem in Spain and in the rest of Europe, and has been acknowledged as such by the European Parliament.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">1</span></a> Since publication of the first article documenting the effectiveness of external cardiac massage,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a> many studies have been made with a view to improving the survival and neurological recovery of patients with OHCA.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Over 50 years later, early intervention on the part of bystanders, starting patient resuscitation, has become established as one of the key determinants of final patient outcome.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">4–8</span></a> However, despite its importance, early resuscitation by bystanders is performed less often that desired. Although the statistics vary greatly, such resuscitation is recorded in barely 30% of the cases of OHCA.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">9</span></a> In our setting the figure is even lower.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">10–15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are contrasted data in the literature showing that telephone support of resuscitation by bystanders (dispatcher-assisted bystander cardiopulmonary resuscitation [CPR]) in both adults and children improves survival following OHCA.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">16</span></a> The resuscitation guides of 2010 recommend the adoption of protocols in the dispatch centers of out-hospital emergency medical services (EMS) designed to identify OHCA and provide first instructions for bystander resuscitation, based on a high level of evidence.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Dispatcher-assisted CPR is defined as the series of instructions delivered by telephone from the EMS coordinating centers with the purpose of favoring collaboration and helping bystanders to apply basic life support measures.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">18–21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain there has been a great increase in scientific production referred to OHCA in recent years. In addition to the results obtained, interest has focused on specific aspects of the different links in the chain of survival,<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">22–31</span></a> aspects related to the resuscitators,<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a> and strategies following resuscitation (post-resuscitation care and non-heart beating donation programs).<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">33–36</span></a> Notoriously, however, no publications in our country have analyzed dispatcher-assisted bystander resuscitation. In fact, a recent survey of the Spanish public EMS conducted in 2013 has shown that only 12 out of 27 services have specific CPR protocols,<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">37</span></a> and each service has moreover developed its own protocol.</p><p id="par0030" class="elsevierStylePara elsevierViewall">These data point to the possibility of improvement, reinforcing transit between the first and second link in the chain of survival by adopting a simple organizational intervention. Clear and homogeneous dispatcher-assisted CPR protocols are needed that are easy to apply in all urgency and emergency care coordination centers in our country. Such protocols should be accompanied by specific training of the dispatchers in identifying OHCA and providing instructions referred to basic life support maneuvers.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">9,38</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objective</span><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of the present project was to develop an expert document on recommendations for promoting dispatcher-assisted bystander cardiopulmonary resuscitation from the EMS coordination centers.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">The Spanish Cardiopulmonary Resuscitation Council (<span class="elsevierStyleItalic">Consejo Español de Resucitación Cardiopulmonar</span>, CERP) is a non-profit scientific-healthcare association founded in 1999 and constituted by different scientific societies, public institutions and EMS with accredited activity in the field of cardiac arrest, life support and CPR.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The CERCP impulsed the creation of a specific work group in urgency and emergency care coordination. The group was formed by the representatives in the CERP of the EMS belonging to Andalusia, Asturias, Galicia and Madrid (<span class="elsevierStyleItalic">SAMUR-Protección Civil</span>). In accordance with the established aim, the group developed a document and a poster draft following a MEDLINE (<a href="http://www.ncbi.nlm.nih.gov/PubMed/">http://www.ncbi.nlm.nih.gov/PubMed/</a>), EMBASE (<a href="http://www.embase.com/">http://www.embase.com</a>) and IME-Biomedicine search (<a href="http://bddoc.csic.es:8080/index.jsp">http://bddoc.csic.es:8080/index.jsp</a>) of articles published between February 2010 and October 2014. The search terms were “dispatch-assisted”, “cardiopulmonary resuscitation” and “emergency medical system”. Some articles were not identified in a first search but were obtained from the references found in that search. A first proposal was forwarded to a panel of experts composed of representatives of the EMS; participants in the Out-of-Hospital Spanish Cardiac Arrest Registry (<span class="elsevierStyleItalic">Registro Español de Parada Cardiaca Extra-Hospitalaria, OHSCAR</span>), a project impulsed by the CERCP and financed by the Spanish <span class="elsevierStyleItalic">Fondo de Investigaciones Sanitarias</span> with the participation of 20 EMS from all over the country (the 17 Spanish Autonomous Communities, the municipal services of Madrid and Zaragoza, and the Emergencies Service of Ceuta) (<a href="http://www.ohscar.org/">www.ohscar.org</a>); the members of the Spanish Group of Pediatric and Neonatal Cardiopulmonary Resuscitation (<span class="elsevierStyleItalic">Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal</span>); and the advisory Scientific Committee of the CERCP.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The basic premises for drafting the recommendations were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Short messages containing key words.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Dispatch (telephone) deliverable.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Understandable (simple language).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Performable by a lay person under difficult conditions.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Presentation in poster format, comprising steps that are easy to follow, with identification and reinforcement of the key actions required.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">To this effect an analysis was made of the steps to be followed in dispatcher-assisted life support instructions, with the identification of a series of key issues:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Recognition of OHCA, identification of the absence of breathing or of ineffective breathing (gasping),<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">38–40</span></a> and indication of an automated external defibrillator.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2.</span><p id="par0090" class="elsevierStylePara elsevierViewall">The provision of instructions to reduce possible rejection to perform CPR on the part of bystanders,<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">41,42</span></a> giving them confidence in performing the necessary maneuvers.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3.</span><p id="par0095" class="elsevierStylePara elsevierViewall">Evidence on the specific telephone instructions regarding the recommended strategy, i.e., CPR only with chest compression versus conventional resuscitation with chest compression and ventilation in the adult. The evidence referred to the different age groups was also analyzed.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">43–45</span></a> Likewise, interventional recommendations were included for cases of foreign body-caused airway obstruction.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4.</span><p id="par0100" class="elsevierStylePara elsevierViewall">Consideration of the need for a simple, homogeneous protocol for all the EMS, allowing evaluation of its suitability and impact following the standards recommended in the international literature.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">46</span></a></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">Two rounds of open suggestions were held on the key elements to be included in the recommendations document. After these consultations, the corresponding document and poster were drafted, followed by e-mail distribution to all the participants for their definitive approval.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Two proposals integrating the dispatcher-assisted bystander cardiopulmonary resuscitation recommendations in a single element were analyzed. Given the difficulty of embodying instructions for adults and for children in one same document, the decision was made to develop two separate supportive elements (shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). These posters are accessible in the four official languages in Spain, and can be found on the CERCP website (<a href="http://www.cercp.org/">www.cercp.org</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The unification of protocols can contribute to better identification of situations of OHCA, and to increased CPR interventions by bystanders. This constitutes an intermediate step for promoting training of the coordination center personnel in dispatcher-assisted bystander cardiopulmonary resuscitation (basic life support measures). Likewise, it facilitates the evaluation and comparison of efforts by the emergency coordination centers<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">46</span></a> and, in sum, may be a positive intervention from the public health perspective.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">9</span></a> The different EMS should measure effort in dispatcher-assisted bystander cardiopulmonary resuscitation as part of their quality assurance program.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Once these protocols have been published and distributed among the different EMS, it will be necessary to evaluate their degree of implementation, and in later phases an analysis will be needed of their possible repercussions upon the medical care and survival of patients with OHCA. According to the first unpublished data on the OHSCAR project (prior to this initiative), the dispatcher-assisted bystander cardiopulmonary resuscitation rate is in the order of 5%.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The development and publication of these protocols is an initiative of the CERCP to unify and improve OHCA care through different tools, following the international recommendations,<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">16</span></a> and opens the door to new areas of research in OHCA and CPR.</p><p id="par0130" class="elsevierStylePara elsevierViewall">We consider the presentation and publication of these protocols to be a key element for their diffusion among all the professionals in different settings who are involved and interested in this field of knowledge, and may contribute (as has been demonstrated in other scenarios) to increase the practice of dispatcher-assisted bystander cardiopulmonary resuscitation and improve the survival outcomes in OHCA<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">47</span></a> –though this requires the commitment and participation of all the parts involved.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres527215" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec547527" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres527214" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec547528" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Methods" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-17" "fechaAceptado" => "2015-02-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec547527" "palabras" => array:3 [ 0 => "Cardiopulmonary resuscitation" 1 => "Dispatch assisted" 2 => "Emergency medical services" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec547528" "palabras" => array:3 [ 0 => "Reanimación cardiopulmonar" 1 => "Soporte telefónico" 2 => "Servicios de urgencias médicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dispatch-assisted bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest has been shown as an effective measure to improve the survival of this process. The development of a unified protocol for all dispatch centers of the different emergency medical services can be a first step toward this goal in our environment. The process of developing a recommendations document and the realization of posters of dispatch-assisted cardiopulmonary resuscitation, agreed by different actors and promoted by the Spanish Resuscitation Council, is presented.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El soporte telefónico a la reanimación cardiopulmonar por testigos en casos de parada cardiaca extrahospitalaria se ha demostrado como una medida eficaz para mejorar la supervivencia de este proceso. El desarrollo de un protocolo unificado para todos los centros coordinadores de los diferentes servicios de urgencias extrahospitalarias puede ser un primer paso para conseguir en nuestro entorno dicho objetivo. Se presenta el proceso de elaboración de un documento de recomendaciones y su concreción en carteles o pósters de reanimación cardiopulmonar asistida por teléfono, elaborado y acordado por diferentes agentes e impulsado por el Consejo Español de Resucitación Cardiopulmonar.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García del Águila J, López-Messa J, Rosell-Ortiz F, De Elías Hernández R, Martínez del Valle M, Sánchez-Santos L, et al. Recomendaciones para el soporte telefónico a la reanimación por testigos desde los centros de coordinación de urgencias y emergencias. Med Intensiva. 2015;39:298–302.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1409 "Ancho" => 995 "Tamanyo" => 242381 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dispatch-assisted bystander cardiopulmonary resuscitation in adults.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1384 "Ancho" => 995 "Tamanyo" => 299102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dispatch-assisted bystander cardiopulmonary resuscitation in children.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:47 [ 0 => array:3 [ "identificador" => "bib0240" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Declaración del Parlamento Europeo, de 14 de junio de 2012, sobre la creación de una Semana Europea del Paro Cardiaco. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 14 | 26 |
| 2024 October | 54 | 74 | 128 |
| 2024 September | 53 | 54 | 107 |
| 2024 August | 57 | 73 | 130 |
| 2024 July | 47 | 30 | 77 |
| 2024 June | 54 | 56 | 110 |
| 2024 May | 51 | 39 | 90 |
| 2024 April | 49 | 47 | 96 |
| 2024 March | 52 | 30 | 82 |
| 2024 February | 53 | 40 | 93 |
| 2024 January | 49 | 43 | 92 |
| 2023 December | 44 | 50 | 94 |
| 2023 November | 44 | 43 | 87 |
| 2023 October | 47 | 38 | 85 |
| 2023 September | 41 | 39 | 80 |
| 2023 August | 32 | 13 | 45 |
| 2023 July | 40 | 18 | 58 |
| 2023 June | 41 | 22 | 63 |
| 2023 May | 44 | 32 | 76 |
| 2023 April | 40 | 26 | 66 |
| 2023 March | 73 | 38 | 111 |
| 2023 February | 70 | 31 | 101 |
| 2023 January | 33 | 28 | 61 |
| 2022 December | 75 | 21 | 96 |
| 2022 November | 94 | 40 | 134 |
| 2022 October | 103 | 57 | 160 |
| 2022 September | 88 | 37 | 125 |
| 2022 August | 103 | 44 | 147 |
| 2022 July | 94 | 40 | 134 |
| 2022 June | 59 | 21 | 80 |
| 2022 May | 117 | 49 | 166 |
| 2022 April | 47 | 41 | 88 |
| 2022 March | 68 | 52 | 120 |
| 2022 February | 61 | 40 | 101 |
| 2022 January | 54 | 40 | 94 |
| 2021 December | 73 | 31 | 104 |
| 2021 November | 60 | 44 | 104 |
| 2021 October | 136 | 66 | 202 |
| 2021 September | 51 | 36 | 87 |
| 2021 August | 91 | 36 | 127 |
| 2021 July | 56 | 33 | 89 |
| 2021 June | 52 | 35 | 87 |
| 2021 May | 86 | 46 | 132 |
| 2021 April | 177 | 83 | 260 |
| 2021 March | 73 | 21 | 94 |
| 2021 February | 90 | 33 | 123 |
| 2021 January | 78 | 15 | 93 |
| 2020 December | 40 | 25 | 65 |
| 2020 November | 43 | 16 | 59 |
| 2020 October | 52 | 23 | 75 |
| 2020 September | 41 | 17 | 58 |
| 2020 August | 41 | 19 | 60 |
| 2020 July | 47 | 14 | 61 |
| 2020 June | 46 | 20 | 66 |
| 2020 May | 98 | 12 | 110 |
| 2020 April | 84 | 17 | 101 |
| 2020 March | 63 | 11 | 74 |
| 2020 February | 94 | 44 | 138 |
| 2020 January | 50 | 36 | 86 |
| 2019 December | 72 | 34 | 106 |
| 2019 November | 47 | 34 | 81 |
| 2019 October | 56 | 21 | 77 |
| 2019 September | 50 | 46 | 96 |
| 2019 August | 50 | 19 | 69 |
| 2019 July | 59 | 23 | 82 |
| 2019 June | 49 | 17 | 66 |
| 2019 May | 60 | 26 | 86 |
| 2019 April | 40 | 17 | 57 |
| 2019 March | 49 | 31 | 80 |
| 2019 February | 37 | 26 | 63 |
| 2019 January | 46 | 40 | 86 |
| 2018 December | 46 | 64 | 110 |
| 2018 November | 150 | 54 | 204 |
| 2018 October | 46 | 28 | 74 |
| 2018 September | 34 | 5 | 39 |
| 2018 August | 26 | 8 | 34 |
| 2018 July | 34 | 10 | 44 |
| 2018 June | 27 | 8 | 35 |
| 2018 May | 15 | 4 | 19 |
| 2018 April | 37 | 7 | 44 |
| 2018 March | 27 | 5 | 32 |
| 2018 February | 24 | 8 | 32 |
| 2018 January | 43 | 12 | 55 |
| 2017 December | 43 | 5 | 48 |
| 2017 November | 30 | 9 | 39 |
| 2017 October | 32 | 10 | 42 |
| 2017 September | 34 | 7 | 41 |
| 2017 August | 30 | 10 | 40 |
| 2017 July | 28 | 10 | 38 |
| 2017 June | 35 | 14 | 49 |
| 2017 May | 39 | 9 | 48 |
| 2017 April | 51 | 10 | 61 |
| 2017 March | 39 | 6 | 45 |
| 2017 February | 26 | 6 | 32 |
| 2017 January | 16 | 7 | 23 |
| 2016 December | 34 | 24 | 58 |
| 2016 November | 59 | 25 | 84 |
| 2016 October | 69 | 32 | 101 |
| 2016 September | 66 | 11 | 77 |
| 2016 August | 57 | 16 | 73 |
| 2016 July | 43 | 11 | 54 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 0 | 1 | 1 |
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