Part 4: Systems of Care and Continuous Quality Improvement

    Key Words:
  • cardiac arrest
  • cardiopulminary resuscitation
  • emergency
  • resuscitation
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The science and recommendations discussed in the other Parts of the Guidelines form the backbone of resuscitation. They answer the “why”, “what,” and “when” of performing resuscitation steps. 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. The ideal workflow to accomplish successful resuscitation is highly dependent on the system of care as a whole.

Healthcare delivery requires structure (eg, people, equipment, training, 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). 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).

Figure 1: Taxonomy of systems of care
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Responses to in-hospital cardiac arrest (IHCA) and out of hospital cardiac arrest (OHCA) depend on 2 distinct systems of care. Each system differs in terms of the setting, team, and available resources, as well as the CQI required from the moment the patient becomes unstable until after the patient is discharged.

The chain of survival metaphor was first used almost 25 years ago and is still relevant. It is helpful, though, to create 2 separate chains (Figure 2) to reflect the differences in the steps needed for response to IHCA and for response to OHCA. 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). 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 support, and targeted temperature management. The structure and process elements before the convergence of the 2 chains vary significantly.

Figure 2: System-specific Chains of Survival
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For the best chance of survival in OHCA, a victim depends on:

    Lay rescuers to

  • recognize cardiac arrest
  • call for help
  • initiate CPR
  • provide early defibrillation (public access defibrillation [PAD])

    Professional EMS providers to

  • Assume responsibility for any additional CPR and defibrillation and possible advanced care
  • Transport to an ED or catheterization lab and then to an intensive care unit

Patients in the hospital depend on a system of surveillance and cardiac arrest prevention. However, when IHCA does occur, the best chance for successful outcome requires prompt notification of cardiac arrest team members who may include physicians, nurses, respiratory therapists and others.

The team provides:

  • High quality CPR
  • Prompt defibrillation
  • Advanced cardiovascular life support (when appropriate)

Teamwork and coordination among responders is a critical determinant of patient outcomes. While additional personnel and resources are usually available in the hospital setting, this is not the case in out-of-hospital settings, where paramedics may find themselves with no resources other than those that they brought with them.

Factors which may be common to both in-hospital and out-of-hospital settings are:

  • need for crowd control
  • family presence
  • space constraints
  • transportation difficulties
  • potential device failures

Systems must be in place to address expected and unexpected challenges and the process must be continually monitored and re-examined to address flaws and failures.

The classic resuscitation Chain of Survival concept linked the community to EMS and EMS to hospitals, with hospital care as the destination. But patients with a cardiac emergency may enter the system of care at one of many different points (Figure 3).

Figure 3: Patient’s point of entry
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In-Hospital Cardiac Arrest

Prearrest Rapid Response Systems


Strategies to combat delayed recognition of patient deterioration include increased electronic monitoring of high- risk patients in the form of traditional electrocardiogram (ECG)-based telemetry, newer heart and respiratory rate sensors, and increased clinician surveillance. In addition, composite risk scores, such as the Modified Early Warning Score and more complex, statistically derived algorithms which can include laboratory data, increase the discrimination for detection when compared with single-parameter criteria.

Early Warning Sign Systems, Rapid Response Teams (RRT), and Medical Emergency Team (MET) Systems

For adult patients, RRT or MET systems can be effective in reducing the incidence of cardiac arrest, particularly in general care wards. (Class IIa, Level of Evidence [LOE] C-LD) (2015 Part 4)

Pediatric MET/RRT systems may be considered in facilities where children with high-risk illnesses are cared for on general in-patient units. (Class IIb, LOE C-LD) (2015 Part 4)

The use of Early Warning Sign Systems may be considered for adults and children. (Class IIb, LOE C-LD) (2015 Part 4)

Do Not Attempt Resuscitation Orders and Palliative Care

It is consistent with a system of care to seek patient or family preferences regarding resuscitation measures such as CPR and mechanical ventilation in patients who are admitted to a hospital with advanced age or terminal condition and short life expectancy. In such patients, the attending physician may then issue a do not attempt resuscitation order based on patient or family preference, expectation of outcome and the clinical judgment of experienced providers.

Cardiac Arrest Quality

Optimal performance depends on rigorous pre-event interdisciplinary collaborative planning and practice.

Optimal outcomes require rigorous resuscitation programs that include the cycle of quality improvement:

  • measurement of performance and outcomes,
  • comparison,
  • interventions to improve outcomes,
  • continuous measurement of performance and outcomes.

Resuscitation Team

Crisis resource management principles suggest that preparation for cardiac arrests and resuscitations include a designated, dedicated resuscitation team available 24 hours a day, 7 days a week, with adequate experience, expertise, and training and retraining to maintain skills, minimize errors, and optimize outcomes. Just-in-time, just-in-place training is an excellent manner for the team members to practice so that they can be prepared to use the equipment and work with their colleagues in their actual practice settings.


Recognition of patient deterioration is an element of an IHCA system of care, with physicians, nurses, and staff able to recognize that deterioration. Training programs that improve the early identification of pre-arrest patients have not been well studied.

Hospital-specific resuscitation training can be contextualized for the individual wards and hospital settings to increase familiarity and effectiveness of the resuscitation team and responses to cardiac arrest.


Some form of debriefing is generally considered beneficial. Debriefing for an individual or the team can occur either immediately after the resuscitation event (“hot debriefing”) or at a later date (“cold debriefing”); each has advantages and disadvantages.

It is reasonable for in-hospital systems of care to implement performance-focused debriefing of rescuers after IHCA in both adults and children. (Class IIa, LOE C-LD) (2015 Part 4)

Post–Cardiac Arrest

Patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest in any setting have a complex combination of pathophysiologic processes (post–cardiac arrest syndrome) which includes post-arrest brain injury, post-arrest myocardial dysfunction, systemic ischemia/ reperfusion response, and persistent acute and chronic pathology that may have precipitated the cardiac arrest.

Comprehensive post–cardiac arrest care requires:

  • optimization of hemodynamics,
  • treatment and reversal of precipitating factors
  • targeted temperature management.

Routine implementation of post–cardiac arrest protocols and order sets may be useful to ensure delivery of consistent and optimal care.

If a collaborative and multidisciplinary team of providers, including cardiologists, interventional cardiologists, cardiac electrophysiologists, intensivists, neurologists, nurses, respiratory therapists, and social workers is not readily available within the hospital, an effective system of care would include appropriate structures and processes for interhospital transfer.

Out-of-Hospital Cardiac Arrest


Organized community programs that prepare the lay public to provide bystander CPR and early defibrillation offer the best opportunity for successful resuscitation in the initial minutes after OHCA and represent the community link in the OHCA Chain of Survival.


Bystander CPR can be performed by community members without equipment or professional credentials.

CPR training programs can help build a culture of expectation for chest compressions to be performed in whatever setting cardiac arrest occurs.

CPR training can be accomplished via traditional classes or brief self-instruction media, public policy initiatives, or mass community CPR training in large public venues or can coincide with the implementation of PAD initiatives.

Public-Access Defibrillation

It is recommended that PAD programs for patients with OHCA be implemented in communities with individuals at risk for OHCA. (Class I, LOE C-LD) (2015 Part 4)

Reporting of public AED locations to public service access points (PSAPs formerly called “EMS dispatch centers”) will enable PSAPs to direct bystanders to retrieve nearby AEDs and assist in their use when OHCA occurs.

Community programs that place AEDs in municipal buildings, large public venues, airports, casinos, and schools represent an important link in the Chain of Survival between recognition and activation of the emergency response system.

Emergency Medical Services

Communities are best served by PSAPs that are designed to quickly recognize the occurrence of cardiac arrest, dispatch the nearest appropriate resources, and help bystanders provide immediate care (including dispatcher –guided CPR) before the arrival of EMS.

Dispatcher Identification of Cardiac Arrest

It is recommended that emergency dispatchers determine if the victim is unconscious with abnormal breathing after acquiring the requisite information to determine the location of the event. (Class I, LOE C-LD) (2015 Part 4)

If the victim is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest. (Class IIa, LOE C-LD) (2015 Part 4)

Dispatchers should be educated to identify unconsciousness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions. (Class I, LOE C-LD) (2015 Part 4)

Dispatcher Instruction in CPR

We recommend that emergency dispatch centers offer CPR instructions and empower dispatchers to provide such instructions for adult patients in cardiac arrest. (Class I, LOE C-LD) (2019 SOC)

Dispatchers should instruct callers to initiate CPR for adults with suspected out-of-hospital cardiac arrest. (Class I, LOE C-LD) (2019 SOC)

Use of Social Media to Summon Rescuers

Summoning nearby willing rescuers via dispatcher activation of social media to the scene of an OHCA may lead to initiation of CPR or defibrillation before the arrival of dispatched EMS providers.

Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA. (Class IIb, LOE B-R) (2015 Part 4)

EMS Culture of Excellence

High-performance EMS is a key component of the OHCA system of care.

An EMS culture of excellence reinforces itself through CQI, and, as a result, successful OHCA resuscitations are considered the norm rather than the exception.

Focused CQI review, supported by comprehensive data collection, seeks to evaluate what went right and what went wrong and what could be improved during the resuscitation and apply lessons learned to future resuscitation efforts.

OHCA Quality Metrics

The collection of resuscitation process measures is the underpinning of a system of care’s quality improvement efforts.

High-quality CPR is the foundation on which all resuscitation efforts depend. Chest compression fraction (the percent of total resuscitation time spent compressing the chest), chest compression quality (rate, depth, and chest recoil), and appropriate ventilation rate are fundamental metrics defining high-quality CPR.

ACS and STEMI Systems of Care

The STEMI system of care starts with rapid identification of ACS by EMS providers in the field followed by initial management, then transport to an appropriate facility for definitive care.

The dispatchers may provide prearrival advice (eg, early aspirin administration). On scene, the paramedics will assess quickly; perform a prehospital 12-lead ECG; and administer aspirin, nitrates, and other medications as needed. Prompt identification of STEMI is the key that allows consideration of the method of reperfusion: prehospital fibrinolysis, pre-arrival notification of the hospital for early in-hospital fibrinolysis, and/or specific hospital destination with pre-arrival notification of the catheterization team for primary percutaneous coronary intervention (PPCI).

The decision regarding prehospital fibrinolysis, in-hospital fibrinolysis, or transport directly to a PPCI center is determined by the local system’s resources.

To achieve prompt recognition and treatment of ACS, the 2 systems of care—out of hospital care and in-hospital care—must be integrated.

Transport to Specialized Cardiac Arrest Centers

A regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may be considered. (Class IIb, LOE C-LD) (2015 Part 4)

A regionalized approach to post–cardiac arrest care that includes transport of resuscitated patients directly to specialized Cardiac Arrest Care Centers is reasonable when comprehensive post–cardiac arrest care is not available at local facilities. (Class IIa, LOE C-LD) (2019 SOC)

Continuous Quality Improvement

Successful systems of care in both the in-hospital and out-of-hospital settings engage in CQI. Key concepts in any system of CQI include goal setting, a process-centric focus, measurement, and accountability.

Goal Setting

Define the goals specifically enough that a person and/or system can be held accountable to achieving those goals.

Effecting Change

The best systems are characterized by a drive to continually improve the system’s performance. The individuals and leaders in the system continually assess processes, form hypotheses, design possible improvements, run experiments, check results, and reflect—and then start again.


Goal setting and effecting change are dependent on regular and accurate measurement of process and outcome variables. Significant improvement in arrest outcomes depends on collection, analysis, feedback, and interventions based on data and observations.


Effective CQI requires that one or more individuals be responsible for assessing and analyzing the data collected, evaluating whether goals are being met, determining necessary changes and then implementing those changes.


A systems-of-care approach together with a rigorous process for CQI can lead to improvements in the process for managing patients with cardiac arrest and in improving their outcomes.

Continued improvement in the processes of managing patients before, during, and after cardiac arrest will require intense focus on consistent, clear goals aimed at decreasing incidence of and improving survival from cardiac arrest.

Change will depend on high-quality data measurement, feedback, and comparison and engaged team members willing to be accountable for seeing those goals to fruition while actively working on improving processes.



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Figure 4: Systems of Care
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Authorship and Disclosures

2015 Writing Team

Steven L. Kronick, Chair; Michael C. Kurz; Steve Lin; Dana P. Edelson; Robert  A. Berg; John E. Billi; Jose G. Cabanas; David C. Cone; Deborah B. Diercks; James K. Foster; Reylon A. Meeks; Andrew H. Travers; Michelle Welsford

Table 1: 2015 - Part 4: Systems of Care and Continuous Quality Improvement: 2015 Guidelines Update Writing Group Disclosures


The American Heart Association requests that this document be cited as follows:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 4: Systems of Care and Continuous Quality

© Copyright 2015 American Heart Association, Inc.