• Ying-Chih Ko, Ming-Ju Hsieh, Matthew Huei-Ming Ma, Blair Bigham, Farhan Bhanji, and Robert Greif.
• Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
• Resuscitation. 2020 Dec 1; 157: 156-165.

AimThe aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.MethodsWe searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).ResultsOne cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.ConclusionAlthough only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.Copyright © 2020 Elsevier B.V. All rights reserved.

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