Teamwork and coordination among responders is a critical determinant of patient outcomes. The challenges encountered, however, are different. The level of complexity is high for both in-hospital and out-of-hospital systems. The chain metaphor endures: in any resuscitation, the chain is no stronger than its weakest link. This team provides high-quality CPR, prompt defibrillation, and advanced cardiovascular life support when appropriate. When cardiac arrest occurs, prompt notification and response to a cardiac arrest should result in the smooth interaction of a multidisciplinary team of professional providers, including physicians, nurses, respiratory therapists, and others. In contrast, patients with IHCA depend on a system of appropriate surveillance and prevention of cardiac arrest, which is represented by a magnifying glass in the first link. Ideally, all victims of OHCA receive bystander CPR and defibrillation if not, CPR and defibrillation won’t occur until EMS personnel arrive, and the victim’s chance of survival is then much lower. Lay rescuers must recognize the patient’s arrest, call for help, and initiate CPR and early defibrillation (public-access defibrillation ) until a team of professionally trained emergency medical services (EMS) providers assumes responsibility and then transports the patient to an ED and/or cardiac catheterization lab, and then on to an ICU for post–cardiac arrest care. Patients with OHCA depend on elements within the community for support. As noted above, the structure and process elements before the convergence of the 2 chains, however, vary significantly.įigure 2. This post–cardiac arrest care is depicted as the final link in both chains, symbolized by a hospital bed with a monitor and thermometer, which represent advanced monitoring and targeted temperature management. Regardless of where an arrest occurs, the care following resuscitation converges in the hospital, generally in an emergency department (ED) or intensive care unit (ICU). However, it may be helpful to create 2 separate chains ( Figure 2) to reflect the differences in the steps needed for response to cardiac arrest in the hospital (in-hospital cardiac arrest ) and out of the hospital (out of hospital cardiac arrest ). The chain of survival metaphor, first used almost 25 years ago, 1 is still very relevant. We will set into context the building blocks for a system of care for cardiac arrest, with consideration of the setting, team, and available resources, as well as CQI from the moment the patient becomes unstable until after the patient is discharged. In this Part, we will focus on 2 distinct systems of care: the system for patients who arrest inside the hospital and the one for those who arrest outside it. An effective system of care (Figure 1) comprises all of these elements-structure, process, system, and patient outcomes-in a framework of continuous quality improvement (CQI). Healthcare delivery requires structure (eg, people, equipment, education, prospective registry data collection) and process (eg, policies, protocols, procedures), which, when integrated, produce a system (eg, programs, organizations, cultures) leading to outcomes (eg, patient safety, quality, satisfaction). The ideal work flow to accomplish resuscitation successfully is highly dependent on the system of care as a whole. In a perfectly controlled and predictable environment, such as a laboratory setting, those answers often suffice, but the “how” of actual implementation depends on knowing the “who” and “where” as well. They answer the “why”, “what,” and “when” of performing resuscitation steps. The science and recommendations discussed in the other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) form the backbone of resuscitation. Customer Service and Ordering Information.Stroke: Vascular and Interventional Neurology.Journal of the American Heart Association (JAHA).Circ: Cardiovascular Quality & Outcomes.Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB).
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