The Chain of Survival Steps

The Chain of Survival outlines critical actions to enhance recovery chances for cardiac arrest patients outside hospitals. The links in the American Heart Association Chain of Survival are:

  1. Immediate recognition of out-of-hospital cardiac arrest event and activation of the emergency medical response system
  2. Early, high-quality CPR
  3. Rapid defibrillation
  4. Effective, advanced life support
  5. Integrated post-cardiac arrest care.
  6. Recovery


The goal of an out-of-hospital cardiac arrest event is to restore a healthy heart rhythm and good neurological outcome. Bystanders can help save a cardiac arrest victim's life and improve patient outcomes by addressing the first three links in the AHA Chain of Survival. Action steps that bystanders can follow are explained below.

5 links in the chain of survival

Prevention for Pediatric Patient

In hospitals, preventive measures are crucial. Thus, applying adult cardiac care strategies to children's care, focusing on vital safety initiatives, is recommended. This includes implementing specific laws and guidelines, such as bicycle helmet laws and SIDS prevention, tailored to safeguard children's health.. The goal is to increase bystander rescuer capacity. As a result, we can decrease emergency response times for children ahead of any actual emergency.

Immediate Recognition and Emergency Response Activation

Immediate Recognition and Emergency Response Activation

The foundational principle of the Chain of Survival is that delay in medical care after a cardiac arrest reduces survival chances. Each minute's delay drastically lowers the likelihood of survival, emphasizing the need for immediate and effective emergency response. Therefore, lay rescuers and emergency medical services must aim to have the fastest possible response. If you are on the scene, you must recognize the cardiac arrest as it occurs and ask another bystander to call 911 before taking any other rescue steps.

Many people, unfortunately, either ignore or misinterpret the critical signs of cardiac arrest, choosing to inform relatives over calling emergency services. This delay in seeking immediate medical help can significantly reduce the chances of survival in cardiac emergencies.

Early, High-Quality CPR

Early, High-Quality CPR

Starting CPR immediately can greatly increase survival chances after a cardiac arrest outside the hospital. If untrained, a bystander can perform Hands-only CPR or chest compressions-only CPR.

One of the most commonly held misconceptions about CPR is the idea that there must be at least two breaths between each compression. More than two breaths aren't much help. Therefore, it's much more important that public access defibrillation must be used as soon as possible.

Rescuers should start CPR immediately, with an emphasis on chest compression. Compressing the chest must be performed fast and hard enough.

According to the American Heart Association, the primary components of high-quality CPR are:

  1. The adequate chest compression depth for adults and children is 2-2.4, and 1.5 for infants.
  2. The optimal chest compression rate is 100-120 compressions per minute.
  3. Minimizing interruptions in CPR. If you're slowing down, switch with a fresh rescuer.
  4. Allowing full chest recoil between compressions
  5. Avoiding excessive ventilation (rescue breathing)
Rapid Defibrillation

Rapid Defibrillation

Early, rapid defibrillation is a critical link in the out-of-hospital chain of survival. It involves applying an automated external defibrillator (AED) to a person who is not breathing normally and whose heart rhythm is irregular. Public access defibrillation is used to restore normal heart rhythm and blood flow. If the heart stops beating, the AED delivers a powerful electric current through the chest wall to start the heart beating again, increasing the chances of survival. Defibrillation within 3–5 mins of collapse can produce a survival rate as high as 50–70%. So if public access defibrillation is available, rescuers must use it as soon as possible.

Advanced Life Support by Healthcare Providers

Advanced Life Support by Healthcare Providers

By this phase, medical professionals have taken over medical care, and advanced care will be provided. Advanced Life Support is a set of life-saving protocols and skills that extend Basic Life Support to further support circulation, airway, and adequate ventilation. Paramedics staff and other healthcare professionals are considered Advanced Life Support trained, including advanced scene management and medical care.

A medical professional must evaluate the cardiac patient for any potential cardiac problems like coronary artery diseases, which must be treated immediately. Therefore, the activation of emergency services comes before anything else.

Post-Cardiac Arrest Care

Post-Cardiac Arrest Care

Cardiac arrest survivors often face physical, cognitive, and psychological challenges after they're discharged from the hospital. They may require ongoing therapies and interventions. Therefore, aftercare is still a crucial component of the chain of survival to ensure a lasting recovery.

Referral to appropriate counseling or other support services, including primary care, should be assessed. Health professionals may also find some circumstances distressing, and their employing organizations should have proper support systems when required.

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According to the American Heart Association for Emergency Cardiovascular Care, accurate neurological prognostication in brain-injured cardiac arrest survivors is critical. This ensures that patient with significant potential for recovery is not destined for certain poor outcomes due to care withdrawal. This added step asks care teams to plan to investigate both the causes and the secondary effects of the out-of-hospital cardiac arrest event and ensure treatment continues.

The American Heart Association is committed to supporting research to update both in and out-of-hospital rescue guidelines. This means that the chain will likely improve in the next few years. The current basic life support guidelines still provide a strong outline for thinking about care and remind us that having knowledgeable certified rescuers is supremely important.

Bystander helping a victim that collapsed

Understanding the Chain of Survival

According to studies by the American Heart Association, out-of-hospital cardiac arrest events can affect more than 300,000 people in the United States every year. Three minutes after the attack, a lack of blood flow starts to damage the cardiac arrest patient's brain, and after 10 minutes, the survival rate is close to zero. However, when someone goes into an out-of-hospital cardiac arrest event, there's a series of events that you can follow to improve the survival rate if performed correctly. This is known as the Out-of-Hospital Chain of Survival.

The term Chain of Survival provides a helpful metaphor for the Emergency Cardiovascular Care systems concept elements. When the Chain of Survival was first created, it included early recognition, early access, CPR, ventricular fibrillation and ventricular tachycardia defibrillation, and advanced cardiac life support.

This concept was later adopted by the American Heart Association and other health organizations like International Liaison Committee on Resuscitation. Afterward, the Chain of Survival was reevaluated to emphasize the importance of early recognition and response. As aftercare options expanded to include mild therapeutic hypothermia and other treatments, post-cardiac arrest care was added to the Chain of Survival.

Today's latest version includes the recovery link, which emphasizes out-of-hospital cardiac arrest patients and their caregivers' physical, social, and emotional needs after survivors leave the hospital.

History of the Chain of Survival

The history of the Chain of Survival is tied to the evolution of emergency medical services and the advancements in resuscitation techniques over the years. The concept of the Chain of Survival gained prominence in the late 20th century as medical professionals and researchers recognized the need to create a standardized framework for addressing sudden cardiac arrest and other life-threatening emergencies. One of the earliest mentions of this concept can be traced back to the American Heart Association (AHA), which played a significant role in promoting and disseminating guidelines for CPR and resuscitation techniques.

In the 1980s and 1990s, there was a growing emphasis on educating the public about basic CPR and the use of AEDs. Public awareness campaigns were launched to encourage bystanders to take immediate action when witnessing a cardiac arrest event. Furthermore, advancements in technology led to the development of more user-friendly AEDs that could be used by non-medical personnel.

Over time, various medical organizations, including the AHA, continued to refine the guidelines and protocols related to the Chain of Survival. These organizations advocated for improved training, public access to AEDs, and a greater focus on improving the quality of CPR and other life-saving interventions.

In recent years, advancements in telecommunication and mobile technology have also played a role in enhancing the Chain of Survival. Mobile apps and platforms that facilitate immediate communication with nearby CPR-trained individuals and dispatchers have emerged, enabling quicker response times and potentially saving more lives.

What factors affect the survival rates of patients who receive out-of-hospital care?

Out-of-hospital care is an important part of healthcare, as it allows patients to receive treatment in their homes or other settings where they feel comfortable. Survival rates of patients who receive out-of-hospital care can be influenced by a variety of factors, including:

  • Timeliness of Care: Quick response and intervention by emergency medical services (EMS) can greatly impact survival rates. Patients who receive timely care are more likely to have positive outcomes.
  • Type and Severity of Illness/Injury: The nature and severity of the patient's condition significantly affect their chances of survival. Serious injuries or life-threatening medical conditions may have lower survival rates.
  • Bystander Intervention: Immediate bystander interventions such as cardiopulmonary resuscitation (CPR) for cardiac arrest or controlling bleeding can substantially improve survival rates before EMS arrives.
  • EMS Response Time: The time it takes for EMS to reach the patient plays a crucial role. Faster response times can lead to earlier treatment, which can be vital in critical situations.
  • Quality of EMS Care: The skills and training of the EMS team can impact patient outcomes. Proper assessment, treatment, and transport decisions are essential.
  • Availability of Advanced Interventions: Some out-of-hospital care providers are equipped to perform advanced interventions like defibrillation, advanced airway management, and administering certain medications. These interventions can significantly improve survival rates.
  • Patient Demographics: Factors such as age, gender, overall health, and pre-existing medical conditions can affect a patient's ability to respond positively to out-of-hospital care.
  • Location and Access to Care: Patients in rural or remote areas may have longer response times due to the distance from medical facilities. Access to medical care can impact outcomes.
  • Bystander Communication with EMS: Accurate and detailed information provided by bystanders to EMS can aid in appropriate treatment planning and resource allocation.
  • Transport Time: The time it takes to transport the patient to a medical facility can be critical. Longer transport times may worsen outcomes, especially for time-sensitive conditions like stroke or trauma.
  • Coordination with Hospital Care: Effective communication and coordination between out-of-hospital care providers and receiving hospitals can lead to better patient outcomes.
  • Community Resources and Support: Availability of AEDs (automated external defibrillators) in public spaces, community education on CPR, and other initiatives can impact overall survival rates.
  • Systematic Factors: Healthcare system design, funding, and regulations can influence the quality of out-of-hospital care and subsequently affect survival rates.
  • Research and Continuous Improvement: The incorporation of evidence-based practices, research, and ongoing training for EMS personnel can contribute to better patient care and outcomes.

What's the role of a bystander in the Chain?

The first three steps of the Chain must often be performed by bystanders, whether or not they know the cardiac arrest patient. Therefore, it's vital to that you recognize when cardiac arrest occurs and activate the Emergency Medical Services by calling 911.

But performing Cardiopulmonary Resuscitation and public access defibrillation as soon as possible is key to improving outcomes. According to 2014 statistics, about 45% of out-of-hospital cardiac arrest survivors received CPR from bystanders.

Why did the American Heart Association's Chain of Survival change?

The American Heart Association reports that sudden cardiac arrest survival improved around 2012. However, there haven't been substantive survival increases since. Recently, the American Heart Association determined that aftercare received after hospital discharge was missing in surviving sudden cardiac arrest. As a result, recovery in the Chain of Survival was added to the adult and pediatric in-hospital and out-of-hospital chains of survival. Additionally, almost 500 other recommendations were made to increase cardiac arrest survival rates.

There is no earlier method to reliably identify patients in whom a poor neurological outcome is inevitable, so the American Heart Association's current guidelines for adults also recommend against the withdrawal of life support for at least 72 hours after resuscitation and rewarming from any induced hypothermia.

These changes accompany other notable researched-based changes. For example, the ABC/CAB swap several years ago. Until 2015, the American Heart Association and other health organizations reviewed and updated guidance for CPR every five years.


How can emergency medical personnel improve survival rates for patients who require care outside of a hospital setting?

Emergency medical personnel can improve survival rates for patients who require care outside of a hospital setting by providing prompt and appropriate treatment. This includes assessing the patient's condition, administering necessary medications, and initiating appropriate treatments. Additionally, emergency medical personnel must stay up-to-date on the latest protocols for out-of-hospital care and be prepared to respond quickly to any changes or complications that may arise.

A recent study in the Chain of Survival concept recommends strengthening the four links in the chain of survival according to the guidelines of the AHA Committee on Emergency Cardiac Care. These links include:

  1. Early Access: The study suggests installing an enhanced 911 emergency dispatch system, providing certification training to all emergency medical dispatchers, and implementing community-wide education programs focused on cardiac emergencies. The emphasis is on promoting a proper response by citizens.
  2. Early CPR: The study advocates for the implementation and support of community CPR training programs. These programs should emphasize early recognition, early contact with the EMS system via telephone, and early defibrillation. Training methods should be chosen to increase the likelihood that citizens will initiate CPR. Additionally, targeted CPR programs and dispatcher-assisted CPR are recommended.
  3. Early Defibrillation: The principle of early defibrillation is highlighted. The study suggests training all emergency personnel performing basic CPR to operate automated external defibrillators. It also encourages the more widespread use of these defibrillators by community responders and allied health responders.
  4. Early Advanced Life Support: The study recommends coordinating advanced life support units with first-response units to provide early defibrillation. Procedures should be developed to combine rapid defibrillation by first-response units with quick intubation and administration of intravenous medications by advanced life support units.


What types of treatments and interventions can be used to improve the survival rate of out-of-hospital patients?

To enhance the survival rate of out-of-hospital patients, a range of treatments and interventions can be employed. These encompass fundamental life support measures like CPR and defibrillation, as well as the timely administration of prescribed medications. When required, initiating resuscitation is crucial. Moreover, post-discharge follow-up care plays a vital role in monitoring patients' recovery progress and mitigating potential complications. By employing a comprehensive approach that includes these interventions, healthcare professionals can significantly improve outcomes for individuals who experience medical emergencies outside of a hospital setting.

What are the most common causes of death for patients who do not receive timely out-of-hospital care?

The most common causes of death for patients who do not receive timely out-of-hospital care include cardiac arrest, respiratory failure, stroke, and sepsis. Cardiac arrest is the most common cause of death in out-of-hospital settings, as it is often caused by a lack of oxygen to the heart or an irregular heart rhythm. Respiratory failure is another frequent cause of death in out-of-hospital settings, as it is often caused by a lack of oxygen to the lungs or an inability to breathe effectively. Stroke and sepsis are less common causes of death for out-of-hospital patients but can still result in serious complications and death.


What role do bystanders play in improving survival rates for patients who experience a medical emergency outside of a hospital setting?

Bystanders play a critical role in improving survival rates for patients who experience a medical emergency outside of a hospital setting. Bystanders should be trained in basic first aid and CPR, so they can respond quickly and appropriately when someone experiences a medical emergency. Bystanders should also call 911 immediately, as this is the best way to ensure that the patient receives timely and appropriate care. Additionally, bystanders can help support the patient until medical personnel arrives, providing comfort and reassurance.


What are the most effective treatment options for patients who require out-of-hospital care?

The most effective treatment options for patients who require out-of-hospital care vary depending on the patient's individual needs and condition. Generally speaking. However, medical personnel should provide basic life support such as CPR, defibrillation, and oxygen if necessary. Medications may also be prescribed to alleviate symptoms or stabilize a patient’s condition in order to prevent further complications. Additionally, follow-up care is important for monitoring a patient’s recovery and preventing any further complications.


How can emergency medical services improve response times and increase the chances of survival for patients in need of out-of-hospital care?

Emergency medical services can improve response times and increase the chances of survival for patients in need of out-of-hospital care by implementing various strategies. First, they can ensure that their personnel is well-trained and knowledgeable on the latest protocols for out-of-hospital care. Additionally, they can invest in rapid response vehicles and communication systems to enable them to respond quickly to medical emergencies. Finally, they can collaborate with local hospitals and other healthcare providers to ensure that the patient is able to receive timely and appropriate care in the event of a medical emergency.


What challenges do emergency medical personnel face when providing care outside of a hospital setting?

Emergency medical personnel face various challenges when providing care outside of a hospital setting. One of the most significant challenges is the lack of access to diagnostic imaging and laboratory testing, which can make it difficult to diagnose and treat patients accurately. Additionally, many out-of-hospital settings do not have the same level of resources as a hospital, such as specialized equipment or medications. Furthermore, emergency medical personnel may also encounter environmental hazards or other challenges due to the location of the patient.


What resources are available to help patients and their families prepare for medical emergencies that occur outside of a hospital setting?

There are several resources available to help patients and their families prepare for medical emergencies that occur outside of a hospital setting. First, it is important for everyone to learn how to recognize the signs and symptoms of a medical emergency so they can take action quickly. Additionally, it is important for families to have a plan in place in case of an emergency, such as knowing who should be contacted and where to go for help. There are many first aid and CPR classes available that can provide individuals with the skills and knowledge needed to respond appropriately in an emergency situation.


What can communities do to support emergency medical personnel and improve survival rates for patients who require out-of-hospital care?

Communities can support emergency medical personnel and improve survival rates for patients who require out-of-hospital care by providing them with the resources they need to respond quickly and effectively. This could include investing in rapid response vehicles, communication systems, specialized training, and other equipment necessary for responding to out-of-hospital emergencies. Additionally, communities can also provide financial support for emergency medical personnel, as well as educational opportunities for the public, in order to raise awareness about the importance of recognizing and responding to medical emergencies.

How can public awareness and education improve the effectiveness of the Chain of Survival?

Public awareness and education are critical for improving the effectiveness of the Chain of Survival. Community-wide CPR training is essential, empowering individuals to provide immediate assistance until professional help arrives. Educating the public about the signs of cardiac arrest and the proper use of automated external defibrillators (AEDs) is equally important. Early recognition of cardiac arrest symptoms and prompt activation of emergency services can significantly impact outcomes. By fostering a well-informed and prepared community, the Chain of Survival can be strengthened, increasing the chances of successful interventions during emergencies.

What are the challenges in implementing the Chain of Survival in remote or rural areas?

  • Limited Access to Emergency Services: Remote areas often face challenges with delayed response times due to the distance from emergency medical services.
  • Training Availability: Limited access to healthcare facilities and training programs can hinder community education on CPR and other life-saving techniques.
  • Infrastructure and Communication: Inadequate infrastructure and poor communication networks can impede the coordination of emergency response efforts.

How does the Chain of Survival differ for children and infants compared to adults?

The Chain of Survival for children and infants differs from that for adults due to distinct physiological and anatomical factors. Early recognition of distress signs in pediatric cases is vital, emphasizing the need for tailored education programs. CPR techniques for children and infants also differ, necessitating specialized training to ensure effective intervention. Awareness of unique medical conditions that can lead to cardiac arrest in young individuals is crucial for timely and appropriate responses. By understanding these differences and providing targeted education, communities can enhance their ability to respond effectively to pediatric emergencies.

What are the latest research findings or advancements related to the Chain of Survival?

 Recent research has brought forth several advancements related to the Chain of Survival. These includes:

  • Telecommunicator CPR Instructions: Advances in emergency dispatch systems include telecommunicator-assisted CPR instructions, guiding bystanders through CPR over the phone.
  • Public Access to AEDs: Research emphasizes the importance of increasing public access to AEDs and optimizing their placement in high-traffic areas.
  • Community-Based Interventions: Studies explore community-based interventions, such as mobile health apps, to educate and engage the public in life-saving techniques.

It's essential to note that advancements in emergency medicine and the Chain of Survival are ongoing, and staying updated with guidelines from organizations like the American Heart Association or the European Resuscitation Council is crucial for healthcare professionals and the general public alike.

How does the availability of medical technology and equipment impact the survival rates of out-of-hospital care patients?

The availability of medical technology and equipment is a major factor in the survival rates of out-of-hospital care patients. Access to sophisticated diagnostic tools, such as X-rays, CT scans, ultrasounds, and specialized treatments, can greatly improve the chances of survival for patients in need of emergency care. Additionally, access to advanced medical equipment such as ventilators, defibrillators, and other life-saving devices can also have a significant impact on the survival rates of out-of-hospital care patients.


Successful resuscitation requires quick and coordinated action by trained rescuers, each performing an important role. The chain of survival is an internationally recognized approach to resuscitation and summarizes the essential interventions to improve patient outcomes during medical emergencies. The chain of survival applies to all OHCAs in adults, children, and infants. Early recognition of OHCA, immediate CPR, and early defibrillation remain the key to improving outcomes. The evidence for high-quality post-resuscitation care continues to evolve to improve results further.


  • American Heart Association (AHA)
  • European Resuscitation Council (ERC)
  • International Liaison Committee on Resuscitation (ILCOR)
  • Emergency medical services and sudden cardiac arrest: the "chain of survival" concept (Pubmed)
  • The "chain of survival" concept: how it can save lives (Pubmed)