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Research Questions

  1. What are the variations in OHCA survival among EMS agencies and communities?
  2. Which approaches are system-of-care best practices for OHCA survival?

Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event that is a leading cause of death in the United States. However, it is unclear how to design strategies that can be successfully implemented in emergency medical services (EMS) agencies and broader emergency response systems (such as fire, police, dispatch, and bystanders to OHCA events) in different communities to help improve daily care processes and outcomes in OHCA. The National Heart, Lung, and Blood Institute–funded Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study lays the foundation for future quality improvement efforts in OHCA by identifying, understanding, and validating the best practices adopted within emergency response systems to address these life-threatening events and by addressing potential barriers to implementation of these practices. RAND researchers developed recommendations covering all levels of the prehospital OHCA incident response and the principles of change management necessary to implement those recommendations.

Key Findings

Researchers identified strategies to improve OHCA survival and potential practices to improve care delivery from a system-of-care perspective.

  • Researchers conducted in-depth, semistructured key informant interviews and multidisciplinary focus groups with more than 160 personnel from 911/dispatch, EMS, non-transport fire, and police in nine emergency response systems with high-, intermediate-, and low-survival outcomes.
  • Strategies identified from the qualitative analysis were extracted by two researchers into templates organized by different best-practices categories relating to the OHCA system-of-care to inform our recommendations.
  • Researchers also conducted an environmental scan of peer-reviewed literature. Strategies were deemed applicable for our recommendations according to the level of supporting evidence from all of the qualitative and environmental scan data.

Researchers developed a total of 49 recommended strategies.

  • These strategies address all phases of the prehospital OHCA incident response and the principles of change management necessary to implement the recommendations.
  • The strategies cover the incident, stakeholder, and system levels. Strategies to improve OHCA outcomes can be adopted by individual stakeholders but are also applicable across the system of care.


  • Leverage tools to improve recognition of cardiac arrest for public and frontline providers.
  • Advocate payment models that do not charge patients for high-acuity emergencies.
  • Develop processes for dispatch to use in providing updates to responding units as additional information from the scene becomes available.
  • Foster effective on-scene communication and a culture of constructive criticism.
  • Encourage aggressive CPR and AED intervention by the first emergency personnel on the scene, including police and non-transport fire.
  • For early responders, keep dispatch updated on patient condition and resource needs.
  • Appoint one responder to manage the logistics of the scene.
  • Track the resuscitation team's work in real time using a formal checklist.
  • Provide structured handoffs in an efficient, standardized manner.
  • Conduct a debriefing after a cardiac arrest event.
  • Collect and share information from various sources (i.e., AED recordings, body camera recordings, documentation) and generate reports on all cardiac arrest incidents for quality improvement purposes.
  • Implement community education programs on cardiac arrest recognition, performing CPR, and AED application.
  • Create a standardized training program for each stakeholder tailored to their specific roles.
  • Consider cross-training responders in multiple roles.
  • Develop a structured quality improvement program for cardiac arrest.
  • Establish a culture of open communication among institutional stakeholders.
  • Implement collaborative training opportunities across stakeholders.
  • Consolidate high-cost resources as a mechanism to provide optimal care for the community.
  • Establish a standardized care protocol for all stakeholders.
  • Ensure compatibility of the equipment used across responder groups.
  • Provide feedback on OHCA performance and outcomes to all responder groups.

Research conducted by

This research was funded by the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) and was carried out as a collaboration among researchers from the University of Michigan, within the Quality Measurement and Improvement Program in RAND Health Care, and SaveMiHeart.

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