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The original motivations to develop emergency medical services (EMS) systems were to improve the care of patients suffering from major trauma and out‐of‐hospital cardiac arrest (OHCA). Physicians and resuscitation researchers often focus on patient‐level perspectives of cardiac arrest care (e.g., specific drugs or treatment algorithms). However, the most important factors determining OHCA survival involve the systems of community care.

Recognition that OHCA survival depended on the time intervals from collapse to initiation of CPR and to defibrillation spurred extensive EMS and public safety efforts to achieve faster response and earlier defibrillation. These efforts included the use of firefighters and police officers as first‐responders, training emergency medical technicians (EMTs) to perform defibrillation, and strategic deployment of advanced life support units (systems status management). However, there were, and remain, inherent logistical limits to first‐responder speed.

Development of the automated external defibrillator (AED) led to the concept of public‐access defibrillation (PAD) [1]. The AED emphasized the potential of immediate bystander action in the management of cardiac arrest. Every EMS medical director, manager, and clinician must recognize the importance of this principle. EMS personnel and hospital staff have less influence on OHCA survival than do bystander CPR and AED use (Figure 12.1) [2]. OHCA survival when there is bystander CPR and an AED is used may be as high as 33‐50% [3–5]. State‐level data from the Cardiac Arrest Registry to Enhance Survival (CARES) program (https://mycares.net), including OHCA incidence and survival rates, demonstrate the effect of bystander interventions early in the “chain of survival” (Table 12.1) [6].

Optimal OHCA survival depends on a comprehensive community‐based approach that includes collecting essential OHCA outcome data as part of a continuous quality improvement program to improve care. Programs like CARES and the Pan Asian Resuscitation Outcomes Study (http://www.scri.edu.sg/index.php/networks‐paros) provide communities with the necessary tools to collect OHCA data in an ongoing efficient manner, enabling benchmarking and gauging effectiveness in a real‐world environment [4,7–8]. In King County, Washington, the Resuscitation Academy (http://www.resuscitationacademy.com) was created to help communities develop local quality assurance programs through a 3‐day fellowship program designed specifically for EMS clinicians, administrators, and medical directors.

Implementation of a community systems‐based approach is as important a role for EMS agencies as the direct patient care they deliver. This chapter provides an overview of the system‐level considerations in cardiac arrest resuscitation and care.