Part 12: From Science to Survival Strengthening the Chain of Survival in Every Community ECC in the Community: How to Ensure Effectiveness

ECC in the Community: How to Ensure Effectiveness Many 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.4 The 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.5,6 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.8,9 The shift in emphasis on system evaluation is necessary because the Chain of Survival is necessary for optimal outcome.10