S678CirculationNovember 2, 2010by guest on May 18, 2014Downloaded from
sequence of CPR steps. Laypersons can learn these skillsonline and in courses.In contrast, in a highly specialized environment, such as acritical care unit of a hospital, many of the individual compo-nents of CPR (compression-ventilation-defibrillation) may bemanaged simultaneously. This approach requires choreog-raphy among many highly-trained rescuers who work as anintegrated team.In the prehospital setting, the order of the CPR componentsperformed by the healthcare provider may switch between asequenced and choreographed model depending on the pro-ficiency of the provider and the availability of resources.Quality Improvement in ResuscitationSystems, Process, and OutcomesA Systems ApproachCardiac arrest is an important public health issue. Resus-citation involves a broad spectrum of individual stakehold-ers and groups. Individuals include victims, family mem-bers, rescuers, and healthcare providers. Key stakeholdergroups include the public, emergency medical dispatchers,public safety organizations, EMS systems, hospitals, civicgroups, and policy makers at the local, state, and federallevels.Because the links in the Chain of Survival are interde-pendent, an effective resuscitation strategy requires theseindividuals and groups to work in an integrated fashion andfunction as asystem of care.40Fundamental to a successfulresuscitation system of care is the collective appreciationof the challenges and opportunities presented by the ChainofSurvival.Thusindividualsandgroupsmustworktogether, sharing ideas and information, to evaluate andimprove their resuscitation system. Leadership and ac-countabilityareimportantcomponentsofthisteamapproach.A conceptual appreciation of the system and its workingcomponentsisonlyastartingpoint.Improvingcarerequires assessment of performance. Only when perfor-mance is evaluated can participants in a system effectivelyFigure 3.Simplified Adult BLSAlgorithm.Travers et alPart 4: CPR OverviewS679by guest on May 18, 2014Downloaded from
intervene to improve care. This process of quality im-provement consists of an iterative and continuous cycle of(1) systematic evaluation of resuscitation care and out-come, (2) benchmarking with stakeholder feedback, and(3) strategic efforts to address identified deficiencies (seeFigure 4).There is wide community and hospital variability incardiac arrest survival.3,8,13High-performing systems haveused this continuous quality improvement approach withgreat success,41as have systems that have more recentlyadopted this strategy.42These successes have occurred in avariety of systems, suggesting that all communities andhospitals can substantially improve care and outcomes.Since each system has different characteristics and chal-lenges, there is no single prescriptive strategy for improve-ment. However, each system has an obligation to addressthe fundamental principles of quality improvement: mea-surement, benchmarking, and feedback and change.