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October 28, 1992, Vol 268, No. 16 >
ARTICLE | October 28, 1992

Ensuring Effectiveness of Communitywide Emergency Cardiac Care FREE

JAMA. 1992;268(16):2289-2295. doi:10.1001/jama.1992.03490160159032
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References

IN RECENT YEARS many clinicians, administrators, and researchers have recognized the need to improve the total emergency cardiac care (ECC) system to optimize patient survival. This section presents the structural components of a "chain of survival" required to save victims of out-of-hospital cardiac arrest (Fig 1)1 and presents methods for evaluation of an emergency system. Communities must identify weaknesses in the ECC system, implement modifications, and optimize treatment for these critical patients.2 Methods for achieving an effective emergency medical services (EMS) system as discussed here are Class I recommendations (definitely effective) (see p 2174).

The central issue is whether a community's ECC system results in 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. However, what is optimal in one community may not be possible in all communities. Early reports of high survival in

REFERENCES

1 +
Cummins RO, Ornato JP, Thies WH, Pepe PE.  Improving survival from sudden cardiac arrest: the 'chain of survival' concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation . 1991;;83:1832-1847.
2 +
Weaver WD, Cobb LA, Hallstrom AP, et al.  Considerations for improving survival from out-of-hospital cardiac arrest. Ann Emerg Med . 1986;;15:1181-1186.
3 +
Eisenberg MS, Cummins RO, Damon S, Larsen MP, Hearne TR.  Survival rates from out-of-hospital cardiac arrest: recommendations for uniform definitions and data to report. Ann Emerg Med . 1990;;19:1249-1259.
4 +
Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Haertle R, Hearne TR.  Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med . 1990;;19:179-186.
5 +
Becker LB, Ostrander MP, Barrett J, Kondos GT, CPR Chicago.  Outcome of CPR in a large metropolitan area: where are the survivors? Ann Emerg Med . 1991;;20:355-361.
6 +
Johnson JC.  Quality assurance in EMS.  In: Roush WR, Aranosian RD, Blair TMH, Handal KA, Kellow RC, Stewart RD, eds. Principles of EMS Systems . Dallas, Tex: American College of Emergency Physicians; 1989;.
7 +
US Agency for Health Care Policy and Research. Medical Treatment Effectiveness Research . Rockville, Md: Agency for Health Care Policy and Research; March 1990;.
8 +
Jastremski MS.  In-hospital cardiac arrest: 'the greater the dogma the greater the ignorance.' Ann Emerg Med . In press.
9 +
Cummins RO, Chamberlain DA, Abramson NS, et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. Circulation . 1991;;84:960-975.
10 +
Clawson JJ.  Emergency medical dispatching.  In: Roush WR, Aranosian RD, Blair TMH, Handal KA, Hellow RD, Stewart RD, eds. Principles of EMS Systems: A Comprehensive Text for Physicians . Dallas, Tex: American College of Emergency Physicians; 1989;.
11 +
Pepe PE, Almaguer DR.  Emergency medical services personnel and ground transport vehicles. Probi Crit Care . 1990;;4:470-476.
12 +
Curka PA, Pepe PE, Ginger VF, Sherrard RC.  Computer-aided EMS priority dispatch: ability of a computed triage system to safely spare paramedics from responses not requiring advanced life support. Ann Emerg Med . 1991;;20:446. Abstract.
13 +
Clawson JJ.  Emergency medical dispatch.  In: Kuehl AE, ed. EMS Medical Directors' Handbook . St Louis, Mo: Mosby-Year Book; 1989;:59-90.
14 +
National Association of EMS Physicians.  Emergency medical dispatching: position paper. Prehosp Disaster Med . 1989;;4:163-166.
15 +
Eisenberg MS, Hallstrom AP, Carter WB, Cummins RO, Bergner L, Pierce J.  Emergency CPR instruction via telephone. Am J Public Health . 1985;;75:47-50.
16 +
Kellermann AL, Hackman BB, Somes G.  Dispatcher-assisted cardiopulmonary resuscitation: validation of efficacy. Circulation . 1989;;80:1231-1239.
17 +
Braun O, McCallion R, Fazackerley J.  Characteristics of midsized urban EMS systems. Ann Emerg Med . 1990;;19:536-546.
18 +
Pepe PE, Bonnin MJ, Almaguer DR, et al.  The effect of tiered system implementation on sudden death survival rates. Prehosp Disaster Med . 1989;; 4:71. Abstract.
19 +
Campbell JC, Gratton MC, Robinson WA.  Meaningful response time interval: is it an elusive dream? Ann Emerg Med . 1991;;20:433.
20 +
Kerber RE.  Statement on early defibrillation from the Emergency Cardiac Care Committee, American Heart Association. Circulation . 1991;;83:2233.
21 +
Cummins RO, Eisenberg MS.  Prehospital cardiopulmonary resuscitation: is it effective? JAMA . 1985;;253:2408-2412.
22 +
Ritter G, Wolfe RA, Goldstein S, et al.  The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J . 1985;;110:932-937.
23 +
Bossaert L, Van Hoeyweghen R.  Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest: the Cerebral Resuscitation Study Group. Resuscitation . 1989;;17( (suppl) ):S55-S69.
24 +
Cummins RO, Eisenberg MS, Hallstrom AP, Litwin PE.  Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med . 1985;;3:114-119.
25 +
Troiano P, Masaryk J, Stueven HA, Olson D, Barthell E, Waite EM.  The effect of bystander CPR on neurologic outcome in survivors of prehospital cardiac arrests. Resuscitation . 1989;;17:91-98.
26 +
 Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC), part VII: emergency cardiac care units (in EMS systems). JAMA . 1986;;255:2974-2979.
27 +
 Putting it all together: resuscitation of the patient.  In: Jaffe A, ed. Textbook of Advanced Cardiac Life Support . Dallas, Tex: American Heart Association; 1987;:235-248.
28 +
Cummins RO.  From concept to standard-of-care? review of the clinical experience with automated external defibrillators. Ann Emerg Med . 1989;;18: 1269-1275.
29 +
Stults KR, Brown DD, Kerber RE.  Efficacy of an automated external defibrillator in the management of out-of-hospital cardiac arrest: validation of the diagnostic algorithm and initial clinical experience in a rural environment. Circulation . 1986;;73:701-709.
30 +
Weaver WD, Hill D, Fahrenbruch CE, et al.  Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med . 1988;;319:661-666.
31 +
Wright D, James C, Marsden AK, Mackintosh AF.  Defibrillation by ambulance staff who have had extended training. BMJ . 1989;;299:96-97.
32 +
Paris PM.  EMT-defibrillation: a recipe for saving lives. Am J Emerg Med . 1988;;6:282-287.
33 +
Cummins RO, Thies W.  Encouraging early defibrillation: the American Heart Association and automated external defibrillators. Ann Emerg Med . 1990;;19:1245-1248.
34 +
Cobb LA, Eliastam M, Kerber RE, et al.  Report of the American Heart Association Task Force on the Future of Cardiopulmonary Resuscitation: special report. Circulation . 1992;;85:2346-2355.
35 +
Murphy DM.  Rapid defibrillation: fire service to lead the way. J Emerg Med Serv . 1987;;12:67-71.
36 +
Pepe P.  Advanced cardiac life support: state of the art.  In: Vincent JL, ed. Emergency and Intensive Care . New York, NY: Springer-Verlag NY Inc; 1990;:565-585.
37 +
Pepe PE, Bonnin MJ, Mattox KL.  Regulating the scope of EMS. Prehosp Disaster Med . 1990;;5:59-63.
38 +
Stewart RD.  Medical direction in emergency medical services: the role of the physician. Emerg Med Clin North Am . 1987;;5:119-132.
39 +
Pepe PE, Copass MK.  Prehospital care.  In: Moore EE, Ducker TB, American College of Surgeons, Committee on Trauma, eds. Early Care of the Injured Patient . 4th ed. Philadelphia, Pa: BC Decker; 1990;:34-55.
40 +
Eisenberg MS, Cummins RO, Litwin PE, Hallstrom AP.  Out-of-hospital cardiac arrest: significance of symptoms in patients collapsing before and after arrival of paramedics. Am J Emerg Med . 1986;;4:116-120.
41 +
Pepe PE, Bonnin MJ, Clark PS.  Clinical predictors of survival in paramedicwitnessed cardiac arrest. Prehosp Disaster Med . 1989;;4:71. Abstract.
42 +
Kellermann AL, Staves DR, Hackman BB.  In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support: 'heroic efforts' or an exercise in futility? Ann Emerg Med . 1988;;17:589-594.
43 +
Gray WA, Capone RJ, Most AS.  Unsuccessful emergency medical resuscitation: are continued efforts in the emergency department justified? N Engl J Med . 1991;;325:1393-1398.
44 +
Bonnin MJ, Pepe PE, Clark PS.  Key role of prehospital resuscitation in survival from out-of-hospital cardiac arrest. Ann Emerg Med . 1990;;19:466. Abstract.
45 +
Brown C.  Physiologic measurement of the ventricular fibrillation ECG signal: estimating the duration of ventricular fibrillation. Ann Emerg Med . In press.
46 +
Berryman CR.  Electromechanical dissociation with a directly measurable arterial blood pressure. Ann Emerg Med . 1986;;15:625-626.
47 +
Cummins RO, Graves JR.  Clinical results of standard CPR: prehospital and inhospital.  In: Kaye W, Bircher NG, eds. Cardiopulmonary Resuscitation . New York, NY: Churchill-Livingstone Inc; 1989;.
48 +
Stout J.  System status management. J Emerg Med Serv . 1989;;14: 65-67.
49 +
Pepe PE, Stewart RD.  Role of the physician in the prehospital setting. Ann Emerg Med . 1986;;15:1480-1483.

Figures

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Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Cummins RO, Ornato JP, Thies WH, Pepe PE.  Improving survival from sudden cardiac arrest: the 'chain of survival' concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation . 1991;;83:1832-1847.
2 +
Weaver WD, Cobb LA, Hallstrom AP, et al.  Considerations for improving survival from out-of-hospital cardiac arrest. Ann Emerg Med . 1986;;15:1181-1186.
3 +
Eisenberg MS, Cummins RO, Damon S, Larsen MP, Hearne TR.  Survival rates from out-of-hospital cardiac arrest: recommendations for uniform definitions and data to report. Ann Emerg Med . 1990;;19:1249-1259.
4 +
Eisenberg MS, Horwood BT, Cummins RO, Reynolds-Haertle R, Hearne TR.  Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med . 1990;;19:179-186.
5 +
Becker LB, Ostrander MP, Barrett J, Kondos GT, CPR Chicago.  Outcome of CPR in a large metropolitan area: where are the survivors? Ann Emerg Med . 1991;;20:355-361.
6 +
Johnson JC.  Quality assurance in EMS.  In: Roush WR, Aranosian RD, Blair TMH, Handal KA, Kellow RC, Stewart RD, eds. Principles of EMS Systems . Dallas, Tex: American College of Emergency Physicians; 1989;.
7 +
US Agency for Health Care Policy and Research. Medical Treatment Effectiveness Research . Rockville, Md: Agency for Health Care Policy and Research; March 1990;.
8 +
Jastremski MS.  In-hospital cardiac arrest: 'the greater the dogma the greater the ignorance.' Ann Emerg Med . In press.
9 +
Cummins RO, Chamberlain DA, Abramson NS, et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. Circulation . 1991;;84:960-975.
10 +
Clawson JJ.  Emergency medical dispatching.  In: Roush WR, Aranosian RD, Blair TMH, Handal KA, Hellow RD, Stewart RD, eds. Principles of EMS Systems: A Comprehensive Text for Physicians . Dallas, Tex: American College of Emergency Physicians; 1989;.
11 +
Pepe PE, Almaguer DR.  Emergency medical services personnel and ground transport vehicles. Probi Crit Care . 1990;;4:470-476.
12 +
Curka PA, Pepe PE, Ginger VF, Sherrard RC.  Computer-aided EMS priority dispatch: ability of a computed triage system to safely spare paramedics from responses not requiring advanced life support. Ann Emerg Med . 1991;;20:446. Abstract.
13 +
Clawson JJ.  Emergency medical dispatch.  In: Kuehl AE, ed. EMS Medical Directors' Handbook . St Louis, Mo: Mosby-Year Book; 1989;:59-90.
14 +
National Association of EMS Physicians.  Emergency medical dispatching: position paper. Prehosp Disaster Med . 1989;;4:163-166.
15 +
Eisenberg MS, Hallstrom AP, Carter WB, Cummins RO, Bergner L, Pierce J.  Emergency CPR instruction via telephone. Am J Public Health . 1985;;75:47-50.
16 +
Kellermann AL, Hackman BB, Somes G.  Dispatcher-assisted cardiopulmonary resuscitation: validation of efficacy. Circulation . 1989;;80:1231-1239.
17 +
Braun O, McCallion R, Fazackerley J.  Characteristics of midsized urban EMS systems. Ann Emerg Med . 1990;;19:536-546.
18 +
Pepe PE, Bonnin MJ, Almaguer DR, et al.  The effect of tiered system implementation on sudden death survival rates. Prehosp Disaster Med . 1989;; 4:71. Abstract.
19 +
Campbell JC, Gratton MC, Robinson WA.  Meaningful response time interval: is it an elusive dream? Ann Emerg Med . 1991;;20:433.
20 +
Kerber RE.  Statement on early defibrillation from the Emergency Cardiac Care Committee, American Heart Association. Circulation . 1991;;83:2233.
21 +
Cummins RO, Eisenberg MS.  Prehospital cardiopulmonary resuscitation: is it effective? JAMA . 1985;;253:2408-2412.
22 +
Ritter G, Wolfe RA, Goldstein S, et al.  The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J . 1985;;110:932-937.
23 +
Bossaert L, Van Hoeyweghen R.  Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest: the Cerebral Resuscitation Study Group. Resuscitation . 1989;;17( (suppl) ):S55-S69.
24 +
Cummins RO, Eisenberg MS, Hallstrom AP, Litwin PE.  Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med . 1985;;3:114-119.
25 +
Troiano P, Masaryk J, Stueven HA, Olson D, Barthell E, Waite EM.  The effect of bystander CPR on neurologic outcome in survivors of prehospital cardiac arrests. Resuscitation . 1989;;17:91-98.
26 +
 Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC), part VII: emergency cardiac care units (in EMS systems). JAMA . 1986;;255:2974-2979.
27 +
 Putting it all together: resuscitation of the patient.  In: Jaffe A, ed. Textbook of Advanced Cardiac Life Support . Dallas, Tex: American Heart Association; 1987;:235-248.
28 +
Cummins RO.  From concept to standard-of-care? review of the clinical experience with automated external defibrillators. Ann Emerg Med . 1989;;18: 1269-1275.
29 +
Stults KR, Brown DD, Kerber RE.  Efficacy of an automated external defibrillator in the management of out-of-hospital cardiac arrest: validation of the diagnostic algorithm and initial clinical experience in a rural environment. Circulation . 1986;;73:701-709.
30 +
Weaver WD, Hill D, Fahrenbruch CE, et al.  Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med . 1988;;319:661-666.
31 +
Wright D, James C, Marsden AK, Mackintosh AF.  Defibrillation by ambulance staff who have had extended training. BMJ . 1989;;299:96-97.
32 +
Paris PM.  EMT-defibrillation: a recipe for saving lives. Am J Emerg Med . 1988;;6:282-287.
33 +
Cummins RO, Thies W.  Encouraging early defibrillation: the American Heart Association and automated external defibrillators. Ann Emerg Med . 1990;;19:1245-1248.
34 +
Cobb LA, Eliastam M, Kerber RE, et al.  Report of the American Heart Association Task Force on the Future of Cardiopulmonary Resuscitation: special report. Circulation . 1992;;85:2346-2355.
35 +
Murphy DM.  Rapid defibrillation: fire service to lead the way. J Emerg Med Serv . 1987;;12:67-71.
36 +
Pepe P.  Advanced cardiac life support: state of the art.  In: Vincent JL, ed. Emergency and Intensive Care . New York, NY: Springer-Verlag NY Inc; 1990;:565-585.
37 +
Pepe PE, Bonnin MJ, Mattox KL.  Regulating the scope of EMS. Prehosp Disaster Med . 1990;;5:59-63.
38 +
Stewart RD.  Medical direction in emergency medical services: the role of the physician. Emerg Med Clin North Am . 1987;;5:119-132.
39 +
Pepe PE, Copass MK.  Prehospital care.  In: Moore EE, Ducker TB, American College of Surgeons, Committee on Trauma, eds. Early Care of the Injured Patient . 4th ed. Philadelphia, Pa: BC Decker; 1990;:34-55.
40 +
Eisenberg MS, Cummins RO, Litwin PE, Hallstrom AP.  Out-of-hospital cardiac arrest: significance of symptoms in patients collapsing before and after arrival of paramedics. Am J Emerg Med . 1986;;4:116-120.
41 +
Pepe PE, Bonnin MJ, Clark PS.  Clinical predictors of survival in paramedicwitnessed cardiac arrest. Prehosp Disaster Med . 1989;;4:71. Abstract.
42 +
Kellermann AL, Staves DR, Hackman BB.  In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support: 'heroic efforts' or an exercise in futility? Ann Emerg Med . 1988;;17:589-594.
43 +
Gray WA, Capone RJ, Most AS.  Unsuccessful emergency medical resuscitation: are continued efforts in the emergency department justified? N Engl J Med . 1991;;325:1393-1398.
44 +
Bonnin MJ, Pepe PE, Clark PS.  Key role of prehospital resuscitation in survival from out-of-hospital cardiac arrest. Ann Emerg Med . 1990;;19:466. Abstract.
45 +
Brown C.  Physiologic measurement of the ventricular fibrillation ECG signal: estimating the duration of ventricular fibrillation. Ann Emerg Med . In press.
46 +
Berryman CR.  Electromechanical dissociation with a directly measurable arterial blood pressure. Ann Emerg Med . 1986;;15:625-626.
47 +
Cummins RO, Graves JR.  Clinical results of standard CPR: prehospital and inhospital.  In: Kaye W, Bircher NG, eds. Cardiopulmonary Resuscitation . New York, NY: Churchill-Livingstone Inc; 1989;.
48 +
Stout J.  System status management. J Emerg Med Serv . 1989;;14: 65-67.
49 +
Pepe PE, Stewart RD.  Role of the physician in the prehospital setting. Ann Emerg Med . 1986;;15:1480-1483.

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