Improve CPR success with systems thinking

Progress on one link in the chain of survival doesn't guarantee success of the other links in the chain of survival

This article was updated by EMS1 Staff on December 12th, 2016 to reflect the most recent data and information on AEDs.

There are ten cellular processes that must continue to function in order for the human body to survive cardiac arrest. While each of these processes is critically important, all require intra- and inter-organizational systems to be in place in order to guarantee success.

The chain of survival exists for a reason. While out-of-hospital cardiac arrest survival rates hover below 6 percent nationally, the successes that are seen require not only adequate clinical interventions but, the seamless functioning of health systems at a regional level [1].

CPR is one of the most resource-heavy processes EMS professionals undertake. It is done with the best of intentions, with an end goal that requires outsmarting the laws of nature. Ensuring success requires that every link in the chain receives appropriate resources and focus.

Bystander CPR saves lives

Training over 10,000 bystanders in the same day to perform hands-only CPR is a product of modern communication technologies. Large CPR training sessions have become so common it exists as a category in the Guinness Book of World Records and attempts to break the current record have been used as a way to increase awareness and engagement within the community. Laerdal has created a webpage dedicated to the concept given the significant logistics required for such an undertaking.

Children that are comfortable with the process have saved the lives of their parents. The idea of training children has become so common that some states are starting to require it in schools.

Even those without training have been able to rely on dispatchers for the encouragement and necessary instructions to bring loved ones back to life. In some cities, total strangers are responding via smartphone apps to assist until providers arrive.

But remember bystander CPR is only one step in the process. When performed, it increases the chance of survival significantly, but if any other links break, is the effort to train and promote bystanders worth the hype?

Access to AEDs

As with bystander CPR, access to AEDs increases survival. While the presence of AEDs has been popularized in schools, churches and public buildings, those locations are often inaccessible in the moment of need.

Researchers in Toronto showed 8 percent of OHCA weren’t within 100 meters of an AED during the day. After the work day, this number jumped to 28 percent in the evening and 48 percent at night. Research has also shown that the vertical distance between a patient and the AED may matter since those that live in high rise buildings are less likely to survive.

Every publically available AED should be celebrated, but their placement should be scrutinized such that those with the greatest need have the most access. Single deaths can drive structural changes that are resource heavy yet outcome light. Although stories of unnecessary deaths are tragic, those with the most to gain may see the least publicity for their survival.

The locations of AEDs are typically pronounced. The actual units are designed in a way that makes their use as simplistic as possible, but the turmoil associated with cardiac arrests can cause many bystanders to fluster. Potentially resulting in a failure to access the AEDs or focusing so much on their functionality that compressions are inadvertently abandoned. Avoiding these downfalls is only possible with repeated exposure and training of the lay public.

Experienced EMS providers

Practice makes permanent. If perfection is possible, it is only acquired if what is being practiced is done in a way that mirrors the end goal. This can be achieved by simulating the chaos surrounding most cardiac arrests until it is no longer chaotic or participating in enough of them to gain the experience necessary.

In communities where exposure to cardiac arrest patients is limited, simulation becomes even more vital. In communities where cardiac arrest patients are plentiful, agencies must balance access to exposure with the recognition experienced providers likely have the muscle memory and institutional knowledge necessary to perform in a more efficient and effective manner.

As with any other process, proficiency with the procedures performed during cardiac arrest increases with experience. But the average EMS provider exits the field after five years, and those that stay likely receive promotions forcing them to spend more time on administrative duties and less on clinical care. This results in a substantial loss of experience and knowledge caring for time-critical emergencies.

Dissemination of the science

Given the complicated clinical requirements of CPR, the best way to perform it in a given environment will likely remain unknown for decades; and as with any other process, the best way to perform will also depend heavily on the resources available to the community at a specific point in time.

The debate will continue over manual versus mechanical compressions, video versus direct laryngoscopy, epinephrine and its dosage and even the need for any advanced interventions at all.

It is our job to support and foster these debates. To continue the tradition of the current work in Arizona, as well as the recently concluded ROC trials, in a way that allows for the progressive moving of the needle.

Science may move at a snail’s pace, but progress within the science is only as good as its ability to be shared within the entire community. On average, it takes 17 years for an accepted process to become integrated within a scientific community [2].

This explains much of the variation within EMS; however it also means that some communities are practicing in a way that clinical experts condemned over a decade ago. Efforts must be made to influence the speed at which we transfer knowledge so that all agencies, regardless of funding or access to the newest technologies are able to provide their patients with the right type and level of care.

Systems thinking saves lives

Survival requires more than a solid clinical foundation; it requires the system to work as seamlessly as the providers with their hands on the patient. It requires full integration between all the links in the chain. It requires recognizing that saving lives goes beyond a single pair of providers in a single agency. It requires creating processes that make success more easily attainable than failure.


  1. Nichol, G. et al. Regional Systems of Care for Out-of-Hospital: Cardiac Arrest: A Policy Statement from the American Heart Association. Circulation 2010;121:709-729.
  2. Balas EA. From appropriate care to evidence-based medicine. Pediatr Ann. 1998;27:581–4.

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