HomeCirculationVol. 102, No. suppl_1Part 12: From Science to Survival Free AccessOtherDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherDownload EPUBPart 12: From Science to Survival Strengthening the Chain of Survival in Every Community Originally published22 Aug 2000https://doi.org/10.1161/circ.102.suppl_1.I-358Circulation. 2000;102:I-358–I-370Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 22, 2000: Previous Version of Record ECC in the Community: How to Ensure EffectivenessMany clinicians, administrators, and researchers have recognized the need to improve community systems of ECC to optimize patient survival. In 1992 this section of the guidelines described in detail the structural components of a “Chain of Survival.” Eight years later the same systematic, organized, coordinated effort in a community remains the strongest recommendation we can make to save more people from out-of-hospital cardiac arrest.1 The metaphor of links of a chain1A has proved successful across many aspects of resuscitation and ECC. For example, the Utstein guidelines for evaluating outcomes from in-hospital cardiac arrest2 and examining pediatric cardiopulmonary emergencies3 were developed from the Chain of Survival perspective. As originally formulated, the out-of-hospital Utstein guidelines were intended to provide a structure to evaluate an emergency system. The usefulness of the Utstein template has been confirmed by the many communities that have identified weaknesses in the “links” of their ECC system. Communities continue to implement modifications and optimize treatment for their critical out-of-hospital patients.4The central question to be answered is whether a community’s ECC system provides optimal patient survival. Achieving the optimal survival rate for out-of-hospital cardiac arrest in every community is the challenge now and in the future. What is optimal in one community, however, may not be possible in all communities. Early reports of high survival in mid-sized cities provided the EMS prototype adopted by most communities.56 Obstacles to providing care in rural and large metropolitan areas create different challenges for EMS systems.7 Each community will need to examine and devise its own mechanisms to achieve the goal of optimal patient survival. Traditionally, quality assurance in ECC has measured process variables, but the emphasis of quality assurance for cardiac arrest care should be expanded to examine outcome variables in the entire ECC system.89 The shift in emphasis on system evaluation is necessary because the Chain of Survival is necessary for optimal outcome.10The Chain of SurvivalThe 1992 guidelines11 described early access, early CPR, early defibrillation, and early advanced care as essential components of a series of actions designed to reduce the mortality associated with cardiac arrest (Figure 1). These vital links were echoed by the International Liaison Committee on Resuscitation (ILCOR) advisory statements in 1997.12Survival from cardiac arrest depends on a series of critical interventions. If one of these critical actions is neglected or delayed, survival is unlikely. The American Heart Association has used the term “Chain of Survival” to describe this sequence. This chain has 4 interdependent links: early access, early basic CPR, early defibrillation, and early ACLS. The Chain of Survival concept underscores several important principles: If any link in the chain is inadequate, survival rates will be poor. Weakness in system components is the major explanation for variability in survival rates reported over the past 20 years.45Although all links must be strong, the inevitable question always arises: Which link is the most important? Certainly, recognition of the emergency and initiation of the Chain is essential—if no one recognizes the emergency and begins to act, survival will be poor.4 Because rapid defibrillation is the only “sufficient” intervention (ie, defibrillation and only defibrillation can reverse a ventricular fibrillation [VF] arrest), it is often proclaimed to be “the single most important factor in determining survival from adult sudden cardiac arrest.” The truth, however, is even more satisfying and more in keeping with the concept of a “Chain of Survival.” Each link in the Chain of Survival is important (see below).The effectiveness of an ECC system cannot be identified by examining an individual link—the whole system must be evaluated. The survival rate to hospital discharge has emerged as the “gold standard” for determining the effectiveness of treatment of cardiac arrest. Recently, considerable progress has been made in providing clear methodological guidelines for study design, uniform terminology, and reporting of results.51314 This progress should facilitate future research on CPR and implementation of the Chain of Survival in each community. (See Table 1 for definitions of terms.)At least 2 large-scale studies have investigated which patient variables and which emergency system variables were significantly related to survival to hospital discharge.1516 A number of variables (male sex, age, witnessed arrest, etc) had at least some significant relationship with survival. The investigators tried to identify the fewest variables that could explain the greatest differences in survival rates. Surprisingly, most of the differences in survival were explained by just 2 performance variables: the intervals collapse to CPR and collapse to defibrillation. These results provided even more support for the Chain of Survival concept when investigators observed that it was the interaction of early CPR with early defibrillation that was most powerful: without both factors, (1) CPR starting within 5 minutes and (2) defibrillation occurring within 10 minutes, the value of early defibrillation or early CPR was lost. This interaction becomes dramatically clear in a simple 2×2 table (Table 2).The First Link: Early AccessEarly access encompasses the events initiated after the patient’s collapse until the arrival of EMS personnel prepared to provide care. Recognition of early warning signs, such as chest pain and shortness of breath, that encourage patients to activate the emergency response system before collapse is a key component of this link. With a cardiac arrest the following events must occur rapidly: Early identification of the patient’s collapse by someone who activates the systemRapid notification (usually by telephone) of EMS response teamRapid recognition by dispatchers of a potential cardiac arrestRapid dispatch instructions to available EMS responders (first-, second-, and third-tier EMS personnel) to guide them to the patientRapid arrival of EMS responders at the sceneArrival of an EMS responder with all necessary equipment at the patient’s sideIdentification of the cardiac arrestAll of these events must take place before defibrillation or advanced care can occur; each of these events is a vital part of the early access link. In most communities responsibility for these events rests with the EMS telephone system, dispatcher, and responders.The Telephone Call to Activate the Emergency Response System: Key Role of an Area-Wide Dedicated Emergency Telephone NumberWidespread use of a 2- or 3-digit dedicated emergency telephone number has simplified and shortened access to emergency assistance. Many countries have established area-wide emergency telephone numbers. Table 3 displays the emergency telephone number used in many countries throughout the world.17 International travelers can access a website for the emergency numbers of more than 200 countries: http://ambulance.ie.eu.org.Unfortunately, many communities do not have the service of a single EMS telephone number. Providing emergency response service through a dedicated unique number should be a top priority for all communities. Enhanced EMS phone service is preferable.The increasing sophistication of telecommunication systems now makes it possible for emergency medical dispatchers (EMDs) to identify the location and telephone number of the incoming telephone call. This invaluable feature (called “enhanced 911” in the United States) requires a costly software and hardware upgrade. Cellular telephone calls to emergency medical dispatchers cannot be included in such “enhanced services” because only the location of the connecting cell is identified. The amazing growth in the use of cellular phones, however, demands a solution to this problem. Features may be added to cellular telephones and cellular networks to enable tracking of emergency calls from cellular phones. Such features should be mandatory and widely implemented.Emergency Medical Dispatchers and the Emergency Medical Dispatch SystemRapid emergency medical dispatch has emerged as a critical component of the early access link.1819202122 Traditionally, however, the dispatchers who answer the emergency calls were simply that—“dispatchers”—identifying the nature of the call (“fire, police, emergency medical”), the location, and then switching to the appropriate service to receive details. All EMS dispatch systems must be able to immediately answer all emergency medical calls, quickly determine the nature of the emergency, identify the nearest appropriate EMS responder unit(s), dispatch the unit to the scene in <1 minute on average, and provide critical information to EMS responders about the type of emergency.In the late 1980s EMS leaders began to explore whether EMDs could actually stay on the telephone with the callers and offer medical advice to the caller. (See also “Part 3: Adult Basic Life Support.”) This led to the highly successful concept of “prearrival instructions,”2122 in which the EMD quickly interviews the caller to learn more about the emergency. The EMD then offers to give the caller advice or instructions on what to do while waiting for the EMS responders to arrive. Internationally, EMDs now give prearrival instructions, and there is widespread acknowledgment that these instructions have improved outcomes.Simultaneously with the development of protocols for prearrival instructions, Eisenberg and colleagues, in Seattle–King County, Washington, developed and validated CPR instructions for the dispatcher to offer to the caller.2324 These dispatcher-assisted CPR instructions are now standard practice for dispatch centers all over the globe. The “template” instructions first developed in King County have been translated into >10 languages. Dispatcher-directed CPR requires only 2 to 4 hours of additional dispatcher training, and it has been shown in controlled trials to be feasible and effective.242525AAn article in the New England Journal of Medicine in 2000 by Hallstrom and colleagues used EMDs to conduct a prospective, randomized, controlled trial of chest compression–only CPR.25A This work was an indirect confirmation of the success of some of the more controversial instructions in telephone CPR, namely, elimination of the pulse check (too difficult for lay rescuers to perform) and replacing the complicated directions on locating the sternal compression point to a simple “press right between the nipples.” These “controversial” shortcuts in CPR instructions were actually put into service >12 years ago, with no problems resulting from their implementation.The growth of interest in public access defibrillation (PAD) and the growing use of automated external defibrillators (AEDs) by family members of high-risk cardiac patients led to the inevitable question of EMD-assisted defibrillation. Early work by Doherty and colleagues26 in Seattle–King County, Washington, confirmed the ease with which this could be achieved and implemented across large EMS systems. The caller is instructed to place both the AED and the telephone next to the victim. The dispatcher simply listens with the rescuer to the voice prompts of the AED, and together they work through the directions.The EMS Responder SystemThe EMS responder system is usually composed of responders trained in BLS, ACLS, or both.19 The system may provide either a single-tier or multi-tier level of response.27 Most 1-tier systems use ACLS-trained responders (paramedics), although some provide only BLS. Two-tier systems generally provide first-responder units staffed with emergency medical technicians or firefighters close to the scene,19 followed by the second tier of ACLS responders. Two-tier systems in which first responders are trained in early defibrillation are most effective in providing rapid ACLS.628Once dispatched, EMS responders must quickly reach the site of the cardiac arrest, locate the patient, and arrive at the patient’s side with all necessary equipment. The following are important considerations: EMS travel interval—The interval it takes an EMS responder to reach the scene is critical for survival of the cardiac arrest victim. Communities have learned to shorten this interval by adding response vehicles, placing response vehicles strategically, and improving traffic paths. Multi-tiered systems appear to have the fastest response intervals because they have more first-responder units. Many communities report an EMS transit interval of approximately 5 minutes for first responders. This interval is too long when the goal is to provide CPR and defibrillation within 4 minutes of an EMS emergency call. Providing rapid EMS response in rural areas with smaller populations remains a challenge.Locating the patient—Few studies have actually noted the time interval from arrival of EMS responders at the scene address until their arrival at the patient’s side.29 This interval, previously assumed to be negligible, is difficult to document because most systems have no means of recording this time.Carrying the correct equipment—The first EMS responders dispatched to treat a patient with cardiac arrest must carry a defibrillator, oxygen, and airway management equipment.30 They must also arrive at the patient’s side in <4 to 5 minutes if defibrillation is to be performed within 5 minutes of the call.The Second Link: Early CPRBystander CPR is the second link in the Chain of Survival. CPR is most effective when started immediately after the victim’s collapse. Many studies have confirmed the value of early CPR by lay rescuers.15163132333435 The probability of survival approximately doubles when bystanders initiate CPR before the arrival of EMS personnel.15 The contribution of bystander CPR to survival appears particularly significant for infants and children; the best survival from out-of-hospital collapse has been documented among infants resuscitated by parents,36 near-drowning victims who receive immediate CPR,37 and children resuscitated by bystanders.38The 1992 conference recommended the development of community-wide CPR programs in as many locations as possible, including schools, military bases, housing complexes, work sites, and public buildings. Communities need to remove barriers that discourage citizens from learning and performing CPR. Creating community-wide change, however, can be challenging. Several randomized community intervention trials, including one in which a short CPR training video was distributed to various households, failed to show an increased likelihood of either CPR being performed or EMS being called.39404142 Targeting relatives of high-risk persons also failed to show an increased likelihood of CPR being performed in an emergency.43 In contrast, parents of high-risk infants who learn CPR appear to perform it willingly and successfully.36One significant barrier to CPR performance is the complexity of the CPR skills set as commonly taught. Multiple studies have documented poor skills retention by participants in traditional didactic CPR courses.4445 New approaches to teaching CPR, including a simplified curriculum and practice-while-watching and practice-after-watching videos, have been more successful in teaching core skills to participants than traditional courses.46 Computerized prompt devices or web-based instruction may offer benefit for teaching or reviewing the skills of CPR. Innovative approaches are necessary to focus on participant skill acquisition.The Third Link: Early DefibrillationEarly defibrillation is the link in the Chain of Survival that is most likely to improve survival.14748495051 The placement of AEDs in the hands of large numbers of people trained in their use may be the key intervention to increase the chances of survival of patients with out-of-hospital cardiac arrest.51 AEDs are computerized, low-maintenance, user-friendly defibrillators that analyze the victim’s rhythm to determine whether a shockable rhythm is present. When the AED detects a shockable rhythm, it charges, then prompts the rescuer to press a shock button to deliver a shock. These devices are highly accurate (sensitivity for VF and specificity for non-VF >95% for virtually all AEDs) and can significantly reduce the time to defibrillation (see “Part 4: The Automated External Defibrillator”).Early DefibrillationThe AHA, ERC, and ILCOR recommend that every emergency vehicle that may transport cardiac arrest patients be equipped with a defibrillator and that emergency personnel be equipped with, trained to use, and permitted to operate this device.3052 To achieve this goal, the International Association of Fire Chiefs has endorsed equipping fire-suppression units with AEDs.51Several options for rapid defibrillation exist. Although AEDs dominate the BLS level of the EMS market, defibrillation also can be performed with manual or semiautomated external defibrillators. Manual defibrillation requires interpretation of a monitor or rhythm strip and is usually performed by responders trained in ACLS. Even so, manual defibrillation by emergency medical technicians trained to recognize VF improves survival.4753The widespread effectiveness and demonstrated safety of the AED have made it acceptable for use by nonprofessional responders. Lay responders must still be trained in CPR and use of the defibrillators. PAD programs, in which AEDs are placed in the hands of trained rescuers, have had initial success in police departments,5455565758 airplanes,5960 and casinos.61 For early defibrillation programs to be successful, defibrillators must be placed in the hands of rescuers who will arrive before traditional EMS personnel. If time to defibrillation is not shortened, survival will not increase.62With limited EMS resources, defibrillators should be given priority over many other medical devices, such as automatic transport ventilators. The cost of defibrillators has steadily declined, making purchase of these devices more attractive.Participants in the 1992 Guidelines Conference recommended that AEDs be widely available for use by persons who have been appropriately trainedAll firefighting personnel who perform CPR and first aid be equipped with and trained to operate AEDsAEDs be placed in gathering places of >10 000 peopleIn those states in which it is necessary, legislation be enacted to allow all EMS personnel to perform early defibrillationParticipants in the international Guidelines 2000 Conference expressed the opinion that PAD may prove to be the decade’s most effective and successful improvement in ECC (See Public Access Defibrillation in “Part 4: The Automated External Defibrillator”). PAD programs should include the following: Preparation and planningEstablishment of pre-event training and programPost–clinical event monitoring of quality improvement and critical incident stress debriefingThe Fourth Link: Early ACLSEarly ACLS provided by paramedics at the scene is another critical link in the management of cardiac arrest. EMS systems should have sufficient staff to provide a minimum of 2 responders trained in ACLS. Because of the difficulties in treating cardiac arrest in the field, additional responders should be present. In systems with survival rates of >20% for patients with VF, response teams have at a minimum 2 ACLS providers plus 2 BLS personnel at the scene.63 Most experts agree that 4 responders (2 trained in ACLS and 2 trained in BLS) provide the most effective team in resuscitation of cardiac arrest victims. Although not every EMS system can attain this level of response, every system should actively pursue this goal.Research Challenges for the FutureThe best way to evaluate the Chain of Survival in a community is to assess survival to hospital discharge and identify delays in activation of the chain. The best way to improve the Chain of Survival is to develop high levels of evidence needed to refine resuscitation guidelines. To meet these goals, clinical research is essential. This research should use common definitions and terminology to allow comparisons and sharing of information across regions and internationally. The Utstein templates (Figures 2 through 4) should be used.36465The best way to evaluate the strength of the community Chain of Survival is to assess the survival rates achieved by the ECC system. The cost of data collection for a system may be significant, but only through evaluation can systems routinely improve their services. Thus, conference participants strongly endorsed the position that all ECC systems should assess their performance through ongoing evaluation. For evaluation data to be meaningful, it is necessary to compare EMS systems. This in turn requires standardized definitions and terms of reference. Until recently, uniform terminology was not available, producing a cardiac arrest Tower of Babel.5 Survival rates reported in the literature range from 2% to 44%. It is not yet understood whether these profound variations are due to differences in population, treatment protocol, system organization, rescuer skills, or reporting practices.There is now international consensus on the importance of using standard terminology and methods to evaluate survival and the Chain of Survival. Considerable effort has been directed to create clear, unambiguous terminology, establish a uniform method of reporting outcome data, and improve methods of research in cardiac arrest.2364 Improving the ECC system, however, first requires an accurate measurement of the survival rate for each community. This can be achieved by implementing the following recommendations: Develop an evaluation process for the ECC system.Include an accurate assessment of survival rate by using standardized terminology and reporting methods. This focus on quality improvement should identify practical goals, given the structure and demographic characteristics of the local system; identify current performance, including survival rate; identify gaps between goals and current performance; identify strategies to improve system performance; and evaluate whether performance improves with these modifications.Design the evaluation specifically to benefit the local community. As a secondary interest, information should be shared regionally and nationally to help other communities develop optimal systems.In assessing survival, integrate evolving concepts of consensus terminology, data collection, system description, and CPR research methods into EMS systems.Consensus TerminologyThe terms and definitions listed in Table 1, referred to as the Utstein style,2364 were developed by a joint task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Resuscitation Council of Southern Africa, the Australian Resuscitation Council, and the New Zealand Resuscitation Council. These terms are intended as a starting point for achieving uniform terminology. Collectively they represent a major improvement over past practice. The emphasis has been to develop terms that will have universal applicability and replace the imprecise terms previously used in the cardiac arrest literature. The terms and definitions in Table 1 should be used whenever possible to reduce confusion in reporting cardiac arrest data.Data CollectionHundreds of potentially important events start and then stop during the course of a cardiac arrest. Events do not always occur in the same order, nor will all patients experience all events. Despite the complexity of cardiac arrest data, certain minimal data must be gathered (Table 4).Population ServedIt is important to report accurately the size of the population served by the EMS system so that the incidence of cardiac arrest within a community can be calculated (incidence equals number of cardiac arrests per population served per unit of time). Incidence of cardiac arrest may reflect the overall health of a community, which may in turn affect the survival rate. Reporting gender, education, socioeconomic factors, and age allows collection of important epidemiological data and identification of high-risk groups. The level of CPR training in the community also should be reported.Confirmed Cardiac Arrests Considered for Resuscitation, Resuscitations Attempted, and Resuscitations Not AttemptedThe number of unresponsive, pulseless, and breathless persons for whom emergency response personnel are called should be documented. This is the maximum number of cardiac arrest patients to use for analysis. Some patients will be excluded in subsequent analyses (eg, those with traumatic arrests, those “dead on arrival,” or those in whom resuscitation was not attempted). After these exclusions the total number of cardiac arrests should be categorized as “resuscitation attempted” and “resuscitation not attempted,” and the criteria or rationale for nonattempted resuscitations should be reported.Arrest After Arrival of Emergency PersonnelApproximately 10% of cardiac arrest patients collapse after the arrival of emergency personnel.76667 During data analysis these cases should be considered separately from unwitnessed and bystander-witnessed arrests, for 2 reasons. First, the presence or absence of bystander CPR and the call-to-arrival interval do not apply to these patients. Inclusion of arrests witnessed by paramedics with other cases would distort tabulation of the percentage of bystander CPR and measurements of the call-to-arrival interval. Second, patients in this category provide important clinical information that deserves separate analysis.The arrest-after-arrival subgroup may provide one of the best measures of EMS responder performance. Because other symptoms precipitated the call for help, however, the pathophysiological explanation for arrest after arrival may differ from that of sudden, unexpected arrests.Stopping CPR Efforts in the FieldMany studies have shown the futility of transporting patients to the Accident and Emergency Department if return of spontaneous circulation is not achieved with adequate ACLS in the field.686970 Some EMS systems routinely terminate unsuccessful CPR efforts in the field, whereas others transport every patient in whom resuscitation is attempted. No one disputes that the survival rate among these patients is dismally low, at <1%. A dilemma remains over how to determine which patients may benefit from additional care. Reported data should include the number of patients for whom efforts were discontinued at the scene and in the Emergency Department and specific criteria for termination of efforts.Cardiac RhythmsAnalysis of cardiac rhythms is complicated because of the many different abnormal ECG patterns and because most patients experience changing rhythms during a cardiac arrest.71 The distinction between asystole and fine VF should be made for all patients. Deflections on the surface ECG of <1 mm (calibrated at 10 mm/mV) are defined as asystole, whereas ≥1 mm is VF. “Pulseless electrical activity” is a term that includes electromechanical dissociation, pseudoelectromechanical dissociation, idioventricular rhythms, pulseless ventricular escape rhythms, postdefibrillation idioventricular rhythms, and bradyasystolic rhythms. For purposes of uniform reporting, all pulseless rhythms with electrical activity should be included as “other rhythms.” For all cases of cardiac arrest, emergency personnel should report the initial rhythm noted. When a patient arrests after emergency responders arrive, personnel should report the initial rhythm immediately. They should also classify ECG rhythms into 1 of 4 categories: VF, ventricular tachycardia, asystole, and other (all pulseless electrical activity should be included in “other”).OutcomesIn a review of 36 communities,5 11 different working definitions of survivor were reported. Four outcomes that provide the most useful information are (1) return of spontaneous circulation, (2) successful hospital admission, (3) successful hospital discharge, and (4) long-term survival with some assessment of neurological function. This data should be reported.Time Points and IntervalsA great deal of confusion has resulted from the use of imprecise terms for the timing of cardiac arrest events. For example, response time, downtime, and time to definitive care have all had a variety of meanings. For clarity, the times at which an event starts and stops should be referred to as time points. The interval from time point A to time point B should be referred to as the A-to-B interval.Lack of accuracy in documenting time is still a problem. Most communities depend on EMS personnel to accurately document the timing of cardiac arrest events. In reality these times are usually estimated by EMS personnel after the patient has arrived in the Emergency Department. This method is inaccurate. Newer defibrillator/monitors with audio event recorders, notebook computers, bar code readers, and other technologies are available to allow EMS responders to document each event. If these devices can be