Patients in rural areas who suffer a cardiac arrest have had worse outcomes compared to those in urban areas. This is due in part to socioeconomic disparities influencing the underlying risk of cardiovascular disease, availability of emergency medical services, and transport time. In addition, little attention is paid to the workflow of patient care after a pulse has been restored. Improving standardization of care between the time patients arrive in the emergency department through the remainder of their care is an important opportunity to limit the disparities seen in rural areas. The hypothesis that underlies this project is that trending risk-adjusted outcomes over time at a state-level, combined with standardization of post-resuscitation care, will improve outcomes for rural patients and thus decrease rural disparities across the state. This project brings together local expertise in epidemiology, policy reform and qualitative studies to 1) determine the influence of rurality on cardiac arrest mortality using risk-adjusted analysis of all patients treated after cardiac arrest across Maine; and 2) develop a multi-center learning community for hyper-acute post-cardiac arrest management to measure treatment metrics and implement standardization protocols to reduce geographical disparities. In the first aim, we will utilize nationally available emergency medical department data to perform a risk-adjusted analysis of statewide available data to determine how rurality affects overall outcomes across the state and identify the variability of outcome among rural areas. In the second aim, we will develop a learning community in seven centers across rural, regional and tertiary centers to implement established protocols for the hyper-acute management of cardiac arrest care. We will use patient-level data to determine baseline and subsequent benchmark data and measure how this changes over time, while taking into consideration regional resources and differences in health care systems. The completion of this project is a critical step in achieving the long- term goal of creating a method to improve systems of care for the state of Maine that can be replicated in other rural states, which will reduce rural health disparities related to out-of-hospital cardiac arrest. This project is led by Dr. Teresa May, a junior clinical researcher with a background in critical care and neurocritical care who recently completed KL2 training where she studied in-hospital aspects of post-cardiac arrest care. With strong mentorship in the areas of rural health research, complex survey designs, data analysis (Y. Jonk) and increasing access to clinical trials in rural areas and implementation science research (R. Kramer), she is well positioned to succeed. This project represents a unique opportunity for Dr. May to develop experience in data-driven development of multi-center learning communities to standardize and improve efficiency of post-resuscitation care. Project results will be applicable to other rural areas around the country, increasing the impact of this research.