Part 4: Systems of Care and Continuous Quality Improvement 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

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. 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 work flow to accomplish resuscitation successfully is highly dependent on the system of care as a whole. 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). 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. 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. 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. The chain of survival metaphor, first used almost 25 years ago,1 is still very relevant. 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 [IHCA]) and out of the hospital (out of hospital cardiac arrest [OHCA]). Regardless of where an arrest occurs, the care following resuscitation converges …