The perception of emergency cardiac care in the community as a continuum is a well-established concept. According to the 1981 AHA ACLS text, "A model systems approach to emergency cardiac care...must incorporate an appropriate response at both the basic...and advanced...life support levels..." On a broader scale, the systems approach has been an integral tenet of emergency medical services, in general, since its modern development in the U.S. in the late sixties. Similarly, a "rescue chain" model, encompassing the bystander, the ambulance and the hospital, has been used in Europe for over 15 years.

Research and developments in recent years have resulted in a revival of the emphasis on a systems approach for emergency cardiac care. Ever since early defibrillation was recognized as the key determinant of survival from cardiac arrest, there has been a new emphasis on the importance of entering the EMS system without delay and a renewed emphasis on bystander CPR.

The term "Chain of Survival" was coined in 1987 to reflect this revival and to capture the essence of today's ideal system of emergency cardiac care. The critical elements of this system: early access, early CPR, early defibrillation and early advanced life support, were conceptualized as interdependent links in the Chain of Survival.

According to the Chain of Survival model of emergency cardiac care, the likelihood that a victim will survive cardiac arrest increases if each of the elements to the right are addressed.

It is the timely occurrence of each of these key variables in the continuum of care that deter-mines who will live and who will die.

This simple educational design gives unprecedented attention to the need for quick recognition of the cardiac emergency and immediate entry into the EMS system. The new focus is a direct result of research which indicates that excessive delays in EMS access dramatically reduce the chances for survival from cardiac arrest.

Too often, we have come to realize, bystanders who are not trained in CPR fail to recognize the warning signals of cardiac distress. Too often, bystanders who are trained in CPR are unable to act. Those few who do muster the confidence to apply their skills, often unwittingly prolong the first minute of CPR before calling EMS. Then, too often, bystanders have no idea which emergency number they should call. In any of these scenarios, the results are the same: defibrillation is no longer early. Instead, it becomes too little too late.

Promotion of the Chain of Survival concept is one of the key objectives of this publication. First used as a slogan for the 1988 Conference on Citizen CPR, the Chain of Survival has since been used in numerous educational settings, including the 11th Congress of the European Society of Cardiology in Antwerp, the World Disaster and Emergency Congress in Hong Kong, American Heart Association educational materials, and in various local training programs.

We believe widespread adoption of the Chain of Survival concept will help in our common mission to save lives which would otherwise be lost. Maybe it could even make a difference in your community.

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