Regional Systems of Care: The Final Link in the “Chain of Survival” Concept for Out-of-Hospital Cardiac Arrest

Abstract

Out-of-hospital cardiac arrest (OHCA) affects approximately 300,000 people in the United States [1], 280,000 in Europe [2], and 100,000 in Japan [3] each year, with a high mortality. To overcome this time-sensitive condition with a low survival rate, the four links of the “chain of survival” concept were first introduced by Newman [4] in the 1980s as follows: (1) early access to emergency medical care; (2) early cardiopulmonary resuscitation (CPR); (3) early defibrillation; and (4) early advanced cardiac life support. The American Heart Association (AHA) adopted this concept in its 1992 guidelines [5], and the International Liaison Committee on Resuscitation (ILCOR) subsequently echoed this concept. Although the chain of survival was subtly updated and differed among associations/councils globally, a similar concept was implemented until the 2005 guidelines [6–8].

In 2005, the European Resuscitation Council (ERC) revised the final link in the chain of survival concept to a provision for “post-resuscitation care” from “early advanced cardiac life support” [8]. In the 2005 ERC guidelines, the final link is targeted at preserving function, particularly of the brain and heart, and recognizes the importance of restoring quality of life to the cardiac arrest survivor [8]. In 2010, the AHA guidelines implemented a “fifth link”, namely “post-cardiac arrest care”, in addition to the previous four links, as another critical link in the chain of survival concept [9]. In all guidelines, the links before the final link of the “chain of survival” have been simplified with each revision. For example, in the AHA guidelines between 2000 and 2010, the focus is now more on recognition of cardiac arrest for the first link. For the second link, hands-only CPR without rescue breathing is recommended, which is much simpler than conventional CPR. In addition, “Look, Listen, and Feel” has been removed from the algorithm for layperson CPR. For the third link, the defibrillation sequence has been reduced from three stacked shocks to a single shock. For the fourth link, whereas several kinds of medication were recommended in the 2000 guidelines (i.e., epinephrine, atropine, several antiarrhythmic drugs and sodium bicarbonate), these have been greatly reduced in the 2010 guidelines (i.e., only epinephrine and amiodarone). However, the final link, “post-cardiac arrest care”, cannot be simplified, and there is a need for a different, additional, integrated approach to counteract post-cardiac arrest syndrome [8–10].

According to the ILCOR consensus statement for post-cardiac arrest syndrome published in 2008 [10] and the 2010 AHA guidelines [9], one of the main objectives of post-cardiac arrest care after OHCA is to transport the patient to an appropriate hospital with a comprehensive post-cardiac arrest treatment system of care that includes acute coronary intervention, neurological care, goal-directed critical care, and therapeutic hypothermia. At that time, however, limited evidence existed to support the implementation of regional systems of care for post-cardiac arrest patients [9, 10]. In this chapter, we review the recent evidence for providing regional systems of care for post-cardiac arrest care in the final link of the “chain of survival” concept for OHCA.