6.5 Systems of Care and Handoffs
Key Takeaways
- Survival depends on coordinated systems (Chains of Survival), not heroics by one rescuer; out-of-hospital and in-hospital chains differ.
- The links are recognition and activation, immediate high-quality CPR, rapid defibrillation, advanced resuscitation, post-arrest care, and recovery.
- Destination matters: route STEMI to PCI, stroke to a stroke center, and refractory or special-cause arrest to capable facilities.
- A structured handoff communicates downtime, rhythm sequence, shocks, drugs, airway, ETCO2, ROSC time, current vitals, and suspected cause.
- Closed-loop communication, defined roles, and clear safety calls ("clear!") underpin every successful transition of care.
6.5 Systems of Care
No single rescuer saves a cardiac-arrest patient; a system does. The AHA frames this as the Chain of Survival, and there are now distinct chains for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) because the resources and rescuers differ.
The links in the chain
| Link | OHCA | IHCA |
|---|---|---|
| 1 | Recognition and activation of the emergency response (call 911) | Surveillance and prevention (early warning, rapid response) |
| 2 | Immediate high-quality CPR (bystander) | Recognition and activation of the emergency response |
| 3 | Rapid defibrillation (public-access AED) | Immediate high-quality CPR |
| 4 | Advanced resuscitation by EMS | Rapid defibrillation |
| 5 | Post-cardiac arrest care | Advanced resuscitation and post-cardiac arrest care |
| 6 | Recovery | Recovery |
The newest link, recovery, reflects rehabilitation, psychological support, and survivorship after discharge. Every weak link (delayed recognition, no bystander CPR, slow defibrillation, poor post-arrest care) lowers survival, so quality-improvement programs measure each step.
Destination decisions
Where the patient goes is part of the system:
- STEMI -> PCI-capable hospital for emergent reperfusion.
- Acute stroke -> stroke-capable center (primary or comprehensive) with prehospital notification.
- Refractory VF/pVT or special causes (severe hypothermia, toxins, suspected pulmonary embolism) -> facilities with ECPR/ECMO or specialty capability when available.
- Post-ROSC -> ICU-level care with temperature control and coronary evaluation.
Handoffs and Communication
Care is lost or duplicated at transitions. A clean handoff moves the right information from rescuer to EMS, EMS to ED, and code team to ICU/cath/stroke teams. Use a structured format (many systems use SBAR: Situation, Background, Assessment, Recommendation, or an arrest-specific script).
What a resuscitation handoff must contain
- Downtime: witnessed or unwitnessed collapse, bystander CPR yes/no, no-flow and low-flow times.
- Rhythm sequence: initial rhythm and any changes (e.g., VF -> PEA -> ROSC).
- Defibrillation: number of shocks and energies.
- Drugs: epinephrine doses/times, antiarrhythmics, and any antidotes.
- Airway: device in place and ETCO2 value (a trend marker for CPR quality and ROSC).
- ROSC: time of ROSC and total resuscitation time.
- Current status: vitals, blood pressure support, neuro exam, 12-lead findings.
- Suspected cause: the working Hs and Ts and the plan still pending.
The receiving team needs what happened and what still must be done, not an exhaustive chronological narrative.
Team dynamics that protect the handoff
- Closed-loop communication: the leader gives a clear order, the receiver repeats it back, and confirms completion.
- Clear roles and a shared mental model: compressor, airway, IV/drugs, monitor/defibrillator, recorder/timer, and leader.
- Safety calls: "Everyone clear!" with a visual sweep before every shock.
- Constructive intervention: any member who spots an error (wrong dose, missed pulse check) speaks up respectfully and immediately.
Common traps
- A vague handoff such as "we coded him and got him back" with no rhythm, shock, or drug data.
- Omitting ROSC time or the suspected cause, so the next team restarts the diagnostic search.
- Ignoring destination needs (sending a STEMI patient to a non-PCI hospital).
Scenario anchor
The team leader hands off: "Witnessed collapse, bystander CPR, initial VF; three shocks; epinephrine 1 mg twice; amiodarone 300 mg once; intubated, ETCO2 38; ROSC at 14 minutes; current SBP 96 on low-dose norepinephrine; 12-lead shows anterior STEMI; cath lab activated; temperature control started."
Strengthening the Weak Links
Quality-improvement data show that survival rises when communities and hospitals strengthen the modifiable links.
- Early recognition and dispatch: dispatcher-assisted CPR instructions and prompt EMS activation shorten the no-flow interval.
- Bystander CPR: immediate compressions can double or triple survival; this is why Hands-Only CPR is taught to the public.
- Public-access defibrillation (PAD): AEDs in airports, casinos, gyms, and schools allow defibrillation before EMS arrives. For every minute defibrillation is delayed in VF, survival falls roughly 7-10%.
- High-performance EMS and hospital teams: pit-crew CPR, minimal interruptions, and measured CPR quality (compression fraction, rate, depth, ETCO2) carry into the ED.
- Regionalized post-arrest and cardiac/stroke systems: routing to cardiac-arrest receiving centers, PCI centers, and stroke centers improves outcomes.
Extracorporeal CPR (ECPR)
Selected refractory arrests (witnessed, shockable, short low-flow time, reversible cause) may benefit from ECPR - veno-arterial ECMO initiated during ongoing CPR at capable centers. It is a systems capability, not a bedside drug, which is why destination and early activation matter.
Roles in a high-performance team
| Role | Core responsibility |
|---|---|
| Team leader | Directs the resuscitation, assigns roles, keeps the shared mental model |
| Compressor | Delivers compressions, rotates every ~2 minutes |
| Airway | Manages ventilation and the advanced airway, monitors ETCO2 |
| IV/IO and medications | Establishes access, prepares and pushes drugs |
| Monitor/defibrillator | Reads rhythm, charges, and delivers shocks safely |
| Timer/recorder | Tracks cycles, drug times, and shock count; prompts the team |
Debriefing and recovery
After the event, a structured debriefing (data-informed or hot debrief) reviews CPR quality metrics, what went well, and what to improve - this closes the quality loop and supports the team. The recovery link continues for survivors: cardiac and neurologic rehabilitation, screening for anxiety/depression/PTSD, and caregiver support. Systems thinking means the work is not done at ROSC or even at discharge; it continues through survivorship.
Key reminder
Most preventable deaths come from broken links - no bystander CPR, delayed defibrillation, a sloppy handoff, or wrong destination - not from a lack of advanced drugs. The candidate who understands the system, not just the algorithm, makes better priority decisions on the exam and at the bedside.
Which item is the newest link added to the AHA Chain of Survival, reflecting care after hospital discharge?
A team leader orders "Give epinephrine 1 milligram IV now," and the nurse replies "Epinephrine 1 milligram IV, giving it now... epinephrine in." This exemplifies which team-dynamics principle?
Which detail is LEAST essential to include in a structured post-arrest handoff to the receiving ICU team?