AHA Consensus Statement CIR.0b013e31829d8654.full

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AHA Consensus Statement

1

Worldwide, there are >135 million cardiovascular deaths

each year, and the prevalence of coronary heart dis-

ease is increasing.1 Globally, the incidence of out-of-hospi-

tal cardiac arrest ranges from 20 to 140 per 100 000 people,

and survival ranges from 2% to 11%.2 In the United States,

>500 000 children and adults experience a cardiac arrest, and

<15% survive.3–5 This establishes cardiac arrest as one of

the most lethal public health problems in the United States,

© 2013 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31829d8654

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship

or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete

and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on May 7, 2013. A copy of the

document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase

additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

The American Heart Association requests that this document be cited as follows: Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji

F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M; on behalf of the CPR Quality Summit Investigators, the American

Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association.

Circulation. 2013;128:XXX–XXX.

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines

development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.

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23

July

2013

Abstract—The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care" increased the focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is

performed in all resuscitation attempts. There are 5 critical components of high-quality CPR: minimize interruptions in

chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid

excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from

cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR

quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider

ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of

optimal systems of care to increase survival from cardiac arrest. This consensus statement addresses the following key

areas of CPR quality for the trained rescuer: metrics of CPR performance; monitoring, feedback, and integration of

the patient’s response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality

improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and

improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the

hospital, and lay the foundation for further improvements in the future. (Circulation. 2013;128:00-00.)

Key Words: AHA Scientific Statements ◼ cardiac arrest ◼ CPR ◼ CPR quality ◼ outcomes ◼ resuscitation

CPR Quality: Improving Cardiac Resuscitation

Outcomes Both Inside and Outside the Hospital

A Consensus Statement From the American Heart Association

Endorsed by the American College of Emergency Physicians

Peter A. Meaney, MD, MPH, Chair; Bentley J. Bobrow, MD, FAHA, Co-Chair;

Mary E. Mancini, RN, PhD, NE-BC, FAHA; Jim Christenson, MD; Allan R. de Caen, MD;

Farhan Bhanji, MD, MSc, FAHA; Benjamin S. Abella, MD, MPhil, FAHA;

Monica E. Kleinman, MD; Dana P. Edelson, MD, MS, FAHA; Robert A. Berg, MD, FAHA;

Tom P. Aufderheide, MD, FAHA; Venu Menon, MD, FAHA; Marion Leary, MSN, RN;

on behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency

Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care,

Perioperative and Resuscitation

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2 Circulation July 23, 2013

claiming more lives than colorectal cancer, breast cancer,

prostate cancer, influenza, pneumonia, auto accidents, HIV,

firearms, and house fires combined.6 In many cases, as Claude

Beck noted, cardiac arrest victims have “hearts too good to

die.”7 In these cases, prompt intervention can result in suc-

cessful resuscitation. Yet overall survival rates remain low.

Why? An increasing body of evidence indicates that even

after controlling for patient and event characteristics, there is

significant variability in survival rates both across and within

prehospital and in-hospital settings. Examples include the

following:

• In the prehospital setting, among participating centers in

the Resuscitation Outcomes Consortium (ROC) Epistry,

survival from out-of-hospital arrest ranged from 3.0% to

16.3%.3 In the United Kingdom, survival-to-discharge

rates within the National Health Service ambulance sys-

tem ranged from 2% to 12%.8

• In the hospital setting, among participating centers in

the Get With The Guidelines-Resuscitation quality-

improvement program, the median hospital survival rate

from adult cardiac arrest is 18% (interquartile range,

12%–22%) and from pediatric cardiac arrest, it is 36%

(interquartile range, 33%–49%).

• In a hospital setting, survival is >20% if the arrest occurs

between the hours of 7 am and 11 pm but only 15% if the

arrest occurs between 11 pm and 7 am.9 There is signifi-

cant variability with regard to location, with 9% survival

at night in unmonitored settings compared with nearly

37% survival in operating room/postanesthesia care unit

locations during the day.9

• Patient survival is linked to quality of cardiopulmonary

resuscitation (CPR). When rescuers compress at a depth of

<38 mm, survival-to-discharge rates after out-of-hospital

arrest are reduced by 30%.10 Similarly, when rescuers com-

press too slowly, return of spontaneous circulation (ROSC)

after in-hospital cardiac arrest falls from 72% to 42%.11

The variations in performance and survival described in these

studies provide the resuscitation community with an incen-

tive to improve outcomes. To maximize survival from cardiac

arrest, the time has come to focus efforts on optimizing the

quality of CPR specifically, as well as the performance of

resuscitation processes in general.

CPR is a lifesaving intervention and the cornerstone of

resuscitation from cardiac arrest.12–14 Survival from cardiac

arrest depends on early recognition of the event and immediate

activation of the emergency response system, but equally criti-

cal is the quality of CPR delivered. Both animal and clinical

studies demonstrate that the quality of CPR during resuscita-

tion has a significant impact on survival and contributes to the

wide variability of survival noted between and within systems

of care.3,15 CPR is inherently inefficient; it provides only 10%

to 30% of normal blood flow to the heart and 30% to 40%

of normal blood flow to the brain16–19 even when delivered

according to guidelines. This inefficiency highlights the need

for trained rescuers to deliver the highest-quality CPR possible.

Poor-quality CPR should be considered a preventable

harm. In healthcare environments, variability in clinician

performance has affected the ability to reduce healthcare-

associated complications,20 and a standardized approach has

been advocated to improve outcomes and reduce prevent-

able harms.21 The use of a systematic continuous quality

improvement (CQI) approach has been shown to optimize

outcomes in a number of urgent healthcare conditions.22–24

Despite this evidence, few healthcare organizations apply

these techniques to cardiac arrest by consistently monitor-

ing CPR quality and outcomes. As a result, there remains an

unacceptable disparity in the quality of resuscitation care

delivered, as well as the presence of significant opportuni-

ties to save more lives.

Today, a large gap exists between current knowledge of

CPR quality and its optimal implementation, which leads to

preventable deaths attributable to cardiac arrest. Resuscitative

efforts must be tailored to each patient. Cardiac arrest

occurs in diverse settings with varying epidemiology and

resources, yet effective solutions exist to improve CPR qual-

ity in each of these settings. The purpose of the present con-

sensus statement is to stimulate transformative change on a

large scale by providing healthcare practitioners and health-

care systems a tangible framework with which to maximize

the quality of CPR and save more lives. The intent is to fill

the gap between the existing scientific evidence surround-

ing resuscitation (as presented in the "2010 American Heart

Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care" [2010 AHA Guidelines

for CPR and ECC]) and the translation of the guidelines into

routine clinical practice. The approach taken is the use of

expert opinion and interpretation of existing studies to pro-

vide a practical hands-on approach to implementing the 2010

AHA Guidelines for CPR and ECC. Although there are many

factors—population (eg, neonatal), chain of survival (eg,

bystander CPR, postresuscitation care), CPR mechanics (hand

position, duty cycle, airway adjuncts), and education (adult

learning principles, feedback devices during training)—that

impact patient survival, this consensus statement is focused

on the critical parameters of CPR that can be enhanced to help

trained providers optimize performance during cardiac arrest

in an adult or a child.

Four areas related to CPR quality will be addressed:

• Metrics of CPR performance by the provider team

• Monitoring and feedback: options and techniques for

monitoring patient response to resuscitation, as well as

team performance

• Team-level logistics: how to ensure high-quality CPR in

complex settings

• CQI for CPR

In addition, gaps in existing knowledge and technologies

will be reviewed and prioritized and recommendations for

optimal resuscitation practice made.

Methods

The contributors to this statement were selected for their

expertise in the disciplines relevant to adult and pediatric car-

diac resuscitation and CPR quality. Selection of participants

and contributors was restricted to North America, and other

international groups were not represented. After a series of

telephone conferences and webinars between the chair and

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Meaney et al Improving CPR Quality 3

program planning committee, members of the writing group

were selected and writing teams formed to generate the content

of each section. Selection of the writing group was performed

in accordance with the AHA’s conflict of interest management

policy. The chair of the writing group assigned individual con-

tributors to work on 1 or more writing teams that generally

reflected their area of expertise. Articles and abstracts presented

at scientific meetings relevant to CPR quality and systems

improvement were identified through the International Liaison

Committee on Resuscitation’s "2010 International Consensus

on CPR and ECC Science With Treatment Recommendations"

statement and the 2010 International Liaison Committee on

Resuscitation worksheets, PubMed, Embase, and an AHA

master resuscitation reference library. This was supplemented

by manual searches of key articles and abstracts. Statements

generated from literature review were drafted by the writing

group and presented to leaders in CPR quality at a CPR Quality

Summit held May 20–21, 2012, in Irving, TX. Participants

evaluated each statement, and suggested modifications were

incorporated into the draft. Drafts of each section were written

and agreed on by members of the writing team and then sent to

the chair for editing and incorporation into a single document.

The first draft of the complete document was circulated among

writing team leaders for initial comments and editing. A revised

version of the document was circulated among all contributors,

and consensus was achieved. This revised consensus statement

was submitted for independent peer review and endorsed by

several major professional organizations (see endorsements).

The AHA Emergency Cardiovascular Care Committee and

Science Advisory and Coordinating Committee approved the

final version for publication.

Metrics of CPR Performance

by the Provider Team

Oxygen and substrate delivery to vital tissues is the central goal

of CPR during the period of cardiac arrest. To deliver oxygen

and substrate, adequate blood flow must be generated by effec-

tive chest compressions during a majority of the total cardiac

arrest time. ROSC after CPR is dependent on adequate myocar-

dial oxygen delivery and myocardial blood flow during CPR.16–18

Coronary perfusion pressure (CPP, the difference between aor-

tic diastolic and right atrial diastolic pressure during the relax-

ation phase of chest compressions) is the primary determinant

of myocardial blood flow during CPR.25–27 Therefore, maximiz-

ing CPP during CPR is the primary physiological goal. Because

CPP cannot be measured easily in most patients, rescuers should

focus on the specific components of CPR that have evidence to

support either better hemodynamics or human survival.

Five main components of high-performance CPR have

been identified: chest compression fraction (CCF), chest

compression rate, chest compression depth, chest recoil

(residual leaning), and ventilation. These CPR components

were identified because of their contribution to blood flow

and outcome. Understanding the importance of these compo-

nents and their relative relationships is essential for providers

to improve outcomes for individual patients, for educators to

improve the quality of resuscitation training, for administra-

tors to monitor performance to ensure high quality within the

healthcare system, and for vendors to develop the necessary

equipment needed to optimize CPR quality for providers,

educators, and administrators.

Minimize Interruptions: CCF >80%

For adequate tissue oxygenation, it is essential that healthcare

providers minimize interruptions in chest compressions and

therefore maximize the amount of time chest compressions

generate blood flow.12,28 CCF is the proportion of time that

chest compressions are performed during a cardiac arrest. The

duration of arrest is defined as the time cardiac arrest is first

identified until time of first return of sustained circulation. To

maximize perfusion, the 2010 AHA Guidelines for CPR and

ECC recommend minimizing pauses in chest compressions.

Expert consensus is that a CCF of 80% is achievable in a vari-

ety of settings. Data on out-of-hospital cardiac arrest indicate

that lower CCF is associated with decreased ROSC and sur-

vival to hospital discharge.29,30 One method to increase CCF

that has improved survival is through reduction in preshock

pause31; other techniques are discussed later in “Team-Level

Logistics.”

Chest Compression Rate of 100 to 120/min

The 2010 AHA Guidelines for CPR and ECC recommend a

chest compression rate of ≥100/min.28 As chest compression

rates fall, a significant drop-off in ROSC occurs, and higher

rates may reduce coronary blood flow11,32 and decrease the

percentage of compressions that achieve target depth.10,33 Data

from the ROC Epistry provide the best evidence of associa-

tion between compression rate and survival and suggest an

optimum target of between 100 and 120 compressions per

minute.34 Consistent rates above or below that range appear to

reduce survival to discharge.

Chest Compression Depth of ≥50 mm in Adults

and at Least One Third the Anterior-Posterior

Dimension of the Chest in Infants and Children

Compressions generate critical blood flow and oxygen

and energy delivery to the heart and brain. The 2010 AHA

Guidelines for CPR and ECC recommend a single minimum

depth for compressions of ≥2 inches (50 mm) in adults. Less

information is available for children, but it is reasonable to

aim for a compression depth of at least one third of the ante-

rior-posterior dimension of the chest in infants and children

(≈1½ inches, or 4 cm, in infants and ≈2 inches, or 5 cm, in

children).35,36

Although a recent study suggested that a depth of ≥44 mm

in adults may be adequate to ensure optimal outcomes,37 the

preponderance of literature suggests that rescuers often do

not compress the chest deeply enough despite recommenda-

tions.10,37–39 Earlier studies suggested that compressions at a

depth >50 mm may improve defibrillation success and ROSC

in adults.40–43 A recent study examined chest compression

depth and survival in out-of-hospital cardiac arrest in adults

and concluded that a depth of <38 mm was associated with

a decrease in ROSC and rates of survival.10 Confusion may

result when a range of depths is recommended and training

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4 Circulation July 23, 2013

targets differ from operational performance targets. Optimal

depth may depend on factors such as patient size, compres-

sion rate, and environmental features (such as the presence

of a supporting mattress). Outcome studies to date have been

limited by the use of mean compression depth of CPR, the

impact of the variability of chest compression depth, and the

change in chest compliance over time.

Full Chest Recoil: No Residual Leaning

Incomplete chest wall release occurs when the chest com-

pressor does not allow the chest to fully recoil on comple-

tion of the compression.44,45 This can occur when a rescuer

leans over the patient’s chest, impeding full chest expansion.

Leaning is known to decrease the blood flow throughout the

heart and can decrease venous return and cardiac output.46

Although data are sparse regarding outcomes related to lean-

ing, animal studies have shown that leaning increases right

atrial pressure and decreases cerebral and coronary perfu-

sion pressure, cardiac index, and left ventricular myocardial

flow.46–48 Human studies show that a majority of rescuers

often lean during CPR and do not allow the chest to recoil

fully.49,50 Therefore, the expert panel agrees that leaning

should be minimized.

Avoid Excessive Ventilation: Rate <12 Breaths per

Minute, Minimal Chest Rise

Although oxygen delivery is essential during CPR, the

appropriate timeframe for interventions to supplement exist-

ing oxygen in the blood is unclear and likely varies with the

type of arrest (arrhythmic versus asphyxial). The metabolic

demands for oxygen are also substantially reduced in the

patient in arrest even during chest compressions. When sud-

den arrhythmic arrest is present, oxygen content is initially

sufficient, and high-quality chest compressions can circulate

oxygenated blood throughout the body. Studies in animals and

humans suggest that compressions without ventilations may

be adequate early in nonasphyxial arrests.51–54 When asphyxia

is the cause of the arrest, the combination of assisted ventila-

tion and high-quality chest compressions is critical to ensure

sufficient oxygen delivery. Animal and human studies of

asphyxial arrests have found improved outcomes when both

assisted ventilations and high-quality chest compressions are

delivered.55,56

Providing sufficient oxygen to the blood without imped-

ing perfusion is the goal of assisted ventilation during CPR.

Positive-pressure ventilation reduces CPP during CPR,57 and

synchronous ventilation (recommended in the absence of

an advanced airway)35 requires interruptions, which reduces

CCF. Excessive ventilation, either by rate or tidal volume, is

common in resuscitation environments.38,57–60 Although chest

compression−only CPR by bystanders has yielded similar

survival outcomes from out-of-hospital arrest as standard

CPR,38,51,52 there is presently not enough evidence to define

when or if ventilation should be withheld by experienced pro-

viders, and more data will be required.

Rate <12 Breaths per Minute

Current guideline recommendations for ventilation rate

(breaths per minute) are dependent on the presence of an

advanced airway (8 to 10 breaths per minute), as well as the

patient’s age and the number of rescuers present (compres-

sion-to-ventilation ratio of 15:2 versus 30:2). When other rec-

ommended goals are achieved (ie, compression rate of 100

to 120/min, inflation time of 1 second for each breath), these

ratios lead to ventilation rates of between 6 and 12 breaths

per minute. Animal studies have yielded mixed results regard-

ing harm with high ventilation rates,57,61 but there are no data

showing that ventilating a patient at a higher rate is beneficial.

Currently recommended compression-ventilation ratios are

designed as a memory aid to optimize myocardial blood flow

while adequately maintaining oxygenation and CO2 clear-

ance of the blood. The expert panel supports the 2010 AHA

Guidelines for CPR and ECC and recommends a ventilation

rate of <12 breaths per minute to minimize the impact of pos-

itive-pressure ventilation on blood flow.

Minimal Chest Rise: Optimal Ventilation Pressure and

Volume

Ventilation volume should produce no more than visible

chest rise. Positive-pressure ventilation significantly lowers

cardiac output in both spontaneous circulation and during

CPR.57,62–65 Use of lower tidal volumes during prolonged

cardiac arrest was not associated with significant differences

in Pao2

66 and is currently recommended.67 Additionally,

positive-pressure ventilation in an unprotected airway may

cause gastric insufflation and aspiration of gastric contents.

Lung compliance is affected by compressions during car-

diac arrest,68 and the optimal inflation pressure is not known.

Although the conceptual relevance of ventilation pressure

and volume monitoring during CPR is well established, cur-

rent monitoring equipment and training equipment do not

readily or reliably measure these parameters, and clinical

studies supporting the optimal titration of these parameters

during CPR are lacking.

Monitoring and Feedback: Options

and Techniques for Monitoring

Patient Response to Resuscitation

The adage, “if you don’t measure it, you can’t improve it”

applies directly to monitoring CPR quality. Monitoring the

quality and performance of CPR by rescuers at the scene of

cardiac arrest has been transformative to resuscitation sci-

ence and clinical practice. Studies have demonstrated that

trained rescuers often had poor CCF ratios, depth of compres-

sions, and compression-ventilation rates,39,57,58,69 which were

associated with worse outcomes.11,34 With monitoring, there

is increased clarity about optimal preshock pause, CCF, and

chest compression depth.10,29,31 With newer technology capa-

ble of monitoring CPR parameters during resuscitation, inves-

tigators and clinicians are now able to monitor the quality of

CPR in real time. Given the insights into clinical performance

and discoveries in optimal practice, monitoring of CPR qual-

ity is arguably one of the most significant advances in resus-

citation practice in the past 20 years and one that should be

incorporated into every resuscitation and every professional

rescuer program.

The types of monitoring for CPR quality can be classified

(and prioritized) into physiological (how the patient is doing)

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and CPR performance (how the rescuers are doing) metrics.

Both types of monitoring can provide both real-time feed-

back to rescuers and retrospective system-wide feedback. It

is important to emphasize that types of CPR quality monitor-

ing are not mutually exclusive and that several types can (and

should) be used simultaneously.

How the Patient Is Doing: Monitoring the Patient’s

Physiological Response to Resuscitative Efforts

Physiological data during CPR that are pertinent for monitor-

ing include invasive hemodynamic data (arterial and central

venous pressures when available) and end-tidal carbon dioxide

concentrations (etco2). Abundant experimental literature has

established that (1) survival after CPR is dependent on ade-

quate myocardial oxygen delivery and myocardial blood flow

during CPR, and (2) CPP during the relaxation phase of chest

compressions is the primary determinant of myocardial blood

flow during CPR.17,18,25,26,70,71 CPP during cardiac arrest is the

difference between aortic diastolic pressure and right atrial

diastolic pressure but may be best conceptualized as diastolic

blood pressure–central venous pressure. Although the concep-

tual relevance of hemodynamic and etco2 monitoring during

CPR is well established, clinical studies supporting the optimal

titration of these parameters during human CPR are lacking.

Nevertheless, the opinions and clinical experience of experts

at the CPR Quality Summit strongly support prioritizing use of

hemodynamic and etco2 concentrations to adjust compression

technique during CPR when available. Furthermore, the expert

panel recommends a hierarchal and situational contextualiza-

tion of physiological monitoring based on the available data

most closely related to myocardial blood flow:

1. Invasive Monitoring: CPP >20 mm Hg

Successful adult resuscitation is more likely when CPP is

>20 mm Hg and when diastolic blood pressure is >25 to

30 mm Hg.16,17,25–27,72–77 Although optimal CPP has not been

established, the expert panel agrees with the 2010 AHA

Guidelines for CPR and ECC that monitoring and titration

of CPP during CPR is reasonable.13 Moreover, the expert

panel recommends that this physiological target be the pri-

mary end point when arterial and central venous catheters

are in place at the time of the cardiac arrest and CPR. Data

are insufficient to make a recommendation for CPP goals

for infants and children.

2. Arterial Line Only: Arterial Diastolic Pressure

>25 mm Hg

Consistent with these experimental data, limited published

clinical studies indicate that the provision of successful adult

resuscitation depends on maintaining diastolic blood pressure

at >25 mm Hg.26,75,76 The expert panel recommends that this

physiological target be the primary end point when an arterial

catheter is in place without a central venous catheter at the

time of the cardiac arrest and CPR. The 2010 AHA Guidelines

for CPR and ECC recommend “trying to improve quality of

CPR by optimizing chest compression parameters or giv-

ing vasopressors or both” if diastolic blood pressure is <20

mm Hg.13 The expert panel recommends that rescuers titrate

to a diastolic blood pressure >25 mm Hg for adult victims of

cardiac arrest.

3. Capnography Only: etco2 >20 mm Hg

etco2 concentrations during CPR are primarily dependent

on pulmonary blood flow and therefore reflect cardiac out-

put.78,79 Failure to maintain etco2 at >10 mm Hg during

adult CPR reflects poor cardiac output and strongly predicts

unsuccessful resuscitation.80–82 The 2010 AHA Guidelines

for CPR and ECC recommend monitoring etco2 during CPR

to assess blood flow in 2 ways: to improve chest compression

performance if etco2 is <10 mm Hg during CPR and to con-

sider an abrupt sustained increase to a normal value (35 to

40 mm Hg) as an indicator of ROSC.13 The expert panel rec-

ommends that when available, etco2 should be the primary

physiological metric when neither an arterial nor a central

venous catheter is in place at the time of the cardiac arrest

and CPR. On the basis of limited animal data and personal

experience, the expert panel recommends titrating CPR per-

formance to a goal etco2 of >20 mm Hg while not exces-

sively ventilating the patient (rate <12 breaths per minute,

with only minimal chest rise).

How the Rescuers Are Doing: Monitoring

CPR Performance

Monitors to measure CPR performance are now widely avail-

able. They provide rescuers with invaluable real-time feed-

back on the quality of CPR delivered during resuscitative

efforts, data for debriefing after resuscitation, and retrospec-

tive information for system-wide CPR CQI programs. Without

CPR measurement and subsequent understanding of CPR per-

formance, improvement and optimized performance cannot

occur. Providing CPR without monitoring performance can be

likened to flying an airplane without an altimeter.

Routinely available feedback on CPR performance char-

acteristics includes chest compression rate, depth, and recoil.

Currently, certain important parameters (CCF and preshock,

perishock, and postshock pauses) can be reviewed only retro-

spectively, whereas others (ventilation rate, airway pressure,

tidal volume, and inflation duration) cannot be assessed ade-

quately by current technology. Additionally, accelerometers

are insensitive to mattress compression, and current devices

often prioritize the order of feedback by use of a rigid algo-

rithm in a manner that may not be optimal or realistic (eg,

an accelerometer cannot measure depth if there is too much

leaning, so the device will prioritize feedback to correct lean-

ing before correcting depth). Although some software (auto-

mated algorithms) and hardware solutions currently exist

(smart backboard, dual accelerometers, reference markers,

and others), continued development of optimal and widely

available CPR monitoring is a key component to improved

performance.

Human Supervision and Direction of CPR

Visual observation provides qualitative information about

depth and rate of chest compressions, as well as rate and

tidal volume of ventilations. Although invasive hemodynamic

monitoring (via intra-arterial and central venous catheters)

provides superior quantitative data about patients’ physiol-

ogy, direct observation can reveal important artifacts (eg, pads

were not selected on the monitor/defibrillator, “flat” arterial

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6 Circulation July 23, 2013

pressure waveform from a turned stopcock obstructed the arte-

rial line tubing), as well as the recognized limitations of feed-

back technology of CPR performance described above. More

rigorous, semiquantitative determination of chest compres-

sion depth and rate can be developed by rescuers with increas-

ing experience, especially after effective feedback. Healthcare

providers may be accustomed to feel for a pulse as an indica-

tion of the adequacy of chest compression, but pulse palpa-

tion during CPR is fraught with potential problems83–85 and is

therefore not recommended as a reliable means of monitoring

the effectiveness of CPR.28,35 Observers can quickly identify

rescuer-patient mismatch (eg, a 40-kg rescuer versus a 120-kg

patient), as well as recommend switching chest compressors if

a rescuer manifests early signs of fatigue. In addition, observ-

ers can integrate the physiological factors (CPP, arterial relax-

ation pressure, or etco2) with quantitative feedback of CPR

quality parameters (depth, rate, leaning) to best achieve opti-

mal CPR delivery.86

New methods and technology that accurately monitor both

team performance and a patient’s physiology during cardiac

arrest should be developed. These may include additional

markers of perfusion such as ventricular fibrillation waveform

analysis, cerebral oximetry, impedance, and near-infrared

spectroscopy. We challenge both researchers and industry to

provide rescuers with robust solutions to monitor patient and

provider performance.

Team-Level Logistics: How to Ensure

High-Quality CPR in the Complex

Setting of Cardiac Resuscitation

Basic life support skills are generally taught and practiced

individually or in pairs.87 In actual practice, CPR is frequently

performed as part of a full resuscitative effort that includes

multiple rescuers and advanced equipment. These additional

resources allow tasks to be performed in parallel so that CPR

can be optimized while the team determines and treats the

underlying cause of the arrest. However, the performance of

secondary tasks frequently consumes large portions of time

and can detract from CPR quality if not managed carefully.88

Resuscitation team composition varies widely, depending

on location (in hospital versus out of hospital), setting (field,

emergency department, hospital ward), and circumstances.

Little is known about the optimal number and background of

professional rescuers.89 Examples of high-functioning resus-

citation teams for both prehospital and in-hospital cardiac

arrest are presented at http://www.heart.org/cprquality. These

examples are meant to be descriptive of how to maintain high-

quality CPR with varying team size and environment rather

than prescriptive if-then rules.

There are, however, data to suggest that resuscitation team

leadership training and demonstration of leadership behaviors

(eg, setting clear expectations, being decisive, and taking a

hands-off approach) are associated with improved CPR per-

formance, especially an increase in CCF.90–92 As such, it is the

recommendation of the expert panel that every resuscitation

event should have a designated team leader who directs and

coordinates all components of the resuscitation with a cen-

tral focus on delivering high-quality CPR. The team leader’s

responsibility is to organize a team of experts into an expert

team by directing and prioritizing the essential activities.

Interactions of CPR Performance Characteristics

There are no clear data on the interactions between com-

pression fraction, rate or depth of compressions, leaning

while performing compressions, and ventilation. All play a

vital role in the transport of substrate to the vital organs

during arrest. For instance, characteristics of chest compres-

sions may be interrelated (eg, higher rate may be associated

with lower depth, and greater depth may lead to increased

leaning), and in practice, the rescuer may need to alter one

component at a time, holding the others constant so as not

to correct one component at the expense of another. The

expert panel proposes that if the patient is not responding

to resuscitative efforts (ie, etco2 <20 mm Hg), team leaders

should prioritize the optimization of individual components

of chest compression delivery in the following order: (1)

compression fraction, (2) compression rate, (3) compres-

sion depth, (4) leaning, and (5) avoidance of excessive ven-

tilation. This order is recommended in part because of the

strength of the science as discussed in the prior sections (eg,

there is stronger evidence for compression fraction, rate,

and depth than leaning) but also for the sake of feasibility,

as discussed below.

Maximization of CCF

Prompt initiation of compressions is the first step toward maxi-

mizing CCF. However, to achieve a target CCF >80%, careful

management of interruptions is critical. The following strate-

gies minimize both the frequency and duration of interruptions.

Choreograph Team Activities

Any tasks that can be effectively accomplished during ongo-

ing chest compressions should be performed without introduc-

ing a pause (Table 1). Additional tasks for which a pause in

compressions is needed should be coordinated and performed

simultaneously in a “pit crew” fashion. The team leader should

communicate clearly with team members about impending

pauses in compression to enable multiple rescuers to anticipate

and then use the same brief pause to achieve multiple tasks.

Table 1. Compression Pause Requirements for Resuscitation

Tasks

Pause Requirement Task

Generally required Defibrillation

Rhythm analysis

Rotation of compressors

Backboard placement

Transition to mechanical CPR or ECMO

Sometimes required Complicated advanced airway placement in

patients who cannot be ventilated effectively

by bag-valve-mask

Assessment for return of spontaneous

circulation

Generally not required Application of defibrillator pads

Uncomplicated advanced airway placement

IV/IO placement

CPR indicates cardiopulmonary resuscitation; ECMO, extracorporeal

membrane oxygenation; and IV/IO, intravenous/intraosseous.

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Meaney et al Improving CPR Quality 7

Minimize Interruptions for Airway Placement

The optimal time for insertion of an advanced airway dur-

ing management of cardiac arrest has not been established.

An important consideration is that endotracheal intubation

often accounts for long pauses in performance of chest com-

pressions.93 Supraglottic airways can be used as an alter-

native to invasive airways, although a recent large study

showed worse outcomes when supraglottic airways were

compared with endotracheal intubation.94 Patients who can

be ventilated adequately by a bag-mask device may not

need an advanced airway at all.95 If endotracheal intuba-

tion is performed, the experienced provider should first

attempt laryngoscopy during ongoing chest compressions.

If a pause is required, it should be kept as short as possible,

ideally <10 seconds. If a surgical airway is required, a lon-

ger pause may be necessary. However, in all such cases,

the expert panel recommends performing any portion of the

procedure that can be done during ongoing compressions to

minimize the pause.

Avoid Unnecessary Pulse Checks

Manual palpation for a pulse can result in unnecessarily long

pauses and is often unreliable.83,85,96–100 These pauses can often

be avoided when available monitoring (such as an arterial

line or capnography) indicates a level of cardiac output or a

rhythm (such as ventricular fibrillation) that is incompatible

with organ perfusion.

Minimize Perishock Pauses

The preshock phase may be particularly vulnerable to inter-

ruption of chest compressions because of the need to provide

a safe environment for the rescuer. It is important to mini-

mize preshock pauses, because outcomes are improved with

decreasing duration of pauses before shock delivery, possibly

as short as 9 seconds.31,41,101 A strategy of applying the pads

and charging the defibrillator during ongoing chest compres-

sions results in shorter perishock pauses, and this practice is

recommended.33,102 Development of technology that mini-

mizes all interruptions (eg, compression artifact waveform

filters that enable rhythm analysis during ongoing chest com-

pressions)103 in blood flow, particularly around defibrillation,

is encouraged. Chest compressions should be restarted with-

out delay after delivery of the shock. In one study, elimination

of stacked shocks and extension of the duration of CPR from

1 to 2 minutes before postshock rhythm analyses increased

CCF from 48% to 69% and was associated with increased

survival.104

Tight Regulation of Compression Rate

Once chest compressions have begun, achievement of the tar-

get rate is often the easiest parameter to adjust and maintain.

Real-time CPR feedback devices, as well as low-cost solu-

tions such as metronomes and music, are known to decrease

variability and result in compression rates closer to the tar-

get rate of 100 to 120/min.58,105,106 It is essential to continue to

monitor and adjust for degradation in compression rate over

time and after modifications to other parameters.

Maximizing Compression Depth

With CCF optimized and compressions ongoing at a rate of

100 to 120/min, focus should turn to ensuring that compression

depth is ≥50 mm. This parameter is one of the most difficult to

achieve because of the physical force required. However, the

following are some strategies to help ensure adequate depth:

1. Ensure a Firm, Hard Surface

The 2010 AHA Guidelines for CPR and ECC recommend

performing CPR on a firm, hard surface. Backboards are com-

monly used to achieve target depths107–109 and reduce rescuer

exertion,110 but their placement interrupts CPR.111 For this rea-

son, the expert panel recommends placement of a backboard

or firm, hard surface as soon as possible and in coordination

with other mandatory pauses in compressions to minimize

interruption time.

2. Optimize Provider Mechanics of Compressions

Compression mechanics often degrade over time,112 and res-

cuers often do not perceive fatigue before skill deteriora-

tion.113–115 Although the 2010 AHA Guidelines for CPR and

ECC recommend rotating chest compressors every 2 min-

utes,12 large interindividual differences in chest compression

quality exist.114,116 Some can perform good-quality compres-

sions for up to 10 minutes, whereas inadequate chest com-

pression depths have been observed after only 1 minute of

continuous chest compressions114,116 or even at the initiation

of CPR.114,116 Others have demonstrated that a switch at 2

minutes may be trading optimal compressions for significant

leaning after the switch86 and decreased CCF caused by the

frequency of switching.117 The use of feedback devices, espe-

cially visual, can counteract degradation of CPR mechanics

to some degree.118,119 The expert panel recommends that the

team leader monitor compressors for signs of fatigue. If there

is evidence of inadequate compressions being performed by a

rescuer that cannot be corrected with feedback or adjustments

in positioning, responsibility for chest compressions should

be transferred to another team member as quickly as possible,

even if 2 minutes has not passed. With proper communica-

tion and preparation for the handoff, the switch can be accom-

plished in <3 seconds.86

Compression mechanics are affected by rescuer position-

ing, but there is no consensus on the optimal rescuer position

for chest compressions. Although there may be no degradation

in compression quality over a short duration,111,120,121 rescuer

work appears to increase in the standing position compared

with use of a step stool or when kneeling.122,123 In addition,

step stools have been shown to increase compression depth,

especially for rescuers of short stature.124 The expert panel rec-

ommends adjustable-height surface (such as a hospital bed),

that the height of the surface be lowered, or that a step stool be

used to enable rescuers to achieve optimal depth during CPR.

Avoid Leaning

Increasing compression depth is often accompanied by

increased leaning. Leaning is a bigger concern for taller res-

cuers and those using a step stool.124 The expert panel recom-

mends that as modifications are made to achieve the target

depth, rescuers should monitor for leaning and adjust posi-

tioning as necessary to ensure adequate depth without residual

pressure on the patient’s chest between compressions.

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8 Circulation July 23, 2013

Avoid Excessive Ventilation

Unlike the compression characteristics, which have effects

that are intertwined, ventilation is a stand-alone skill that can

be optimized in parallel with chest compressions. Methods to

decrease ventilation rate, such as use of metronomes, are well

established,106,125 whereas methods to limit excessive tidal vol-

ume and inspiratory pressure are less well developed but may

include the use of smaller resuscitation bags, manometers, and

direct observation.66,67,126–128

Additional Logistic Considerations

Incorporation of Mechanical CPR

Trials of mechanical CPR devices to date have failed to

demonstrate a consistent benefit in patient outcomes com-

pared with manual CPR.129–133 The most likely explanation is

that inexperienced rescuers underestimate the time required

to apply the device,134 which leads to a significant decrease

in CCF during the first 5 minutes of an arrest135–137 despite

increases in CCF later in the resuscitation.138 There is evi-

dence that pre-event “pit crew” team training can reduce

the pause required to apply the device.139 Three large-scale

implementation studies (Circulation Improving Resuscitation

Care [CIRC],140 Prehospital Randomized Assessment

of a Mechanical Compression Device in Cardiac Arrest

[PARAMEDIC],141 and LUCAS in Cardiac Arrest [LINC])142

may provide clarity about the optimal timing and environ-

ment for mechanical CPR. In the absence of published evi-

dence demonstrating benefit, the decision to use mechanical

CPR may be influenced by system considerations such as in

rural settings with limited numbers of providers and/or long

transport times.

Patient Transport

Performing chest compressions in a mobile environment has

additional challenges and almost uniformly requires that the

rescuer be unsecured, thus posing an additional safety concern

for providers. Manual chest compressions provided in a mov-

ing ambulance are affected by factors such as vehicle move-

ment, acceleration/deceleration, and rotational forces and can

compromise compression fraction, rate, and depth.143,144 There

is no consensus on the ideal ambulance speed to address these

concerns.145,146 Studies of mechanical versus manual CPR in

a moving ambulance show less effect on CPR quality when a

mechanical device is used.130,147

CPR and Systematic CQI

Systematic CQI has optimized outcomes in a number of

healthcare conditions,22–24 increases safety, and reduces

harm.21 Review of the quality and performance of CPR by

professional rescuers after cardiac arrest has been shown to be

feasible and improves outcomes.40,137,148 Despite this evidence,

few healthcare organizations apply these techniques to cardiac

arrest by consistently monitoring CPR quality and outcomes.

As a result, there remains an unacceptable variability in the

quality of resuscitation care delivered.

Debriefing

An effective approach to improving resuscitation quality on

an ongoing basis is the use of debriefing after arrest events.

In this context, debriefing refers to a focused discussion

after a cardiac arrest event in which individual actions and

team performance are reviewed. This technique can be very

effective for achieving improved performance; CPR quality

is reviewed while the resuscitation is fresh in the rescuer’s

mind. This approach, easily adaptable for either out-of-

hospital or in-hospital cardiac arrest, can take a number

of forms. One simple approach is represented by a “group

huddle” among providers after a resuscitation attempt to

briefly discuss their opinions about quality of care and what

could have been improved. Similar discussions among pro-

viders who actually gave care can be performed on a regu-

larly scheduled basis, and such an approach using weekly

debriefing sessions has been shown to improve both CPR

performance and ROSC after in-hospital cardiac arrest.40

Preexisting structures in hospitals and emergency medical

services (EMS) systems can be efficiently adapted to debrief

A

B

Figure 1. Illustration of proposed resuscitation “report cards.”

Routine use of a brief tool to document resuscitation quality

would assist debriefing efforts and quality improvement efforts

for hospital and emergency medical services systems. A, General

checklist. Example of a general checklist report card that could

be completed by a trained observer to a resuscitation event.

B, CPR quality analysis. Example of a report card that relies on

objective recording of CPR metrics. Ideally, both observational

(A) and objective (B) reports could be used together in a

combined report. CPR indicates cardiopulmonary resuscitation.

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Meaney et al Improving CPR Quality 9

arrest events. This has also been confirmed by a number

of simulation studies among rescuers of both pediatric and

adult victims of cardiac arrest.149,150 If this approach is taken,

it is crucial that the actual care providers be present for the

discussion.

Use of Checklists

Debriefing can be greatly enhanced by structuring the discus-

sion; that is, basing it on a quality checklist prompted by a

short set of questions on quality metrics. Short CPR check-

lists can provide invaluable feedback directly from multiple

sources. Systems should develop or adapt CPR quality check-

lists as CQI tools. These postevent checklists can be as simple

as a short debriefing checklist (Figure 1 [“report card”]) on

specific quality metrics that can be easily filled out after arrest

events.

Use of Monitoring Data

Inclusion of monitoring data (physiological response of the

patient to resuscitative efforts, performance of CPR by the

provider) can provide an excellent data set for debriefing,

because it allows a more objective approach that avoids per-

ceptions of judgmental feedback. Every EMS system, hospi-

tal, and other professional rescuer program should strongly

consider acquiring technology to capture CPR quality data for

all cardiac arrests. Equipment that measures metrics of CPR

performance must be able to provide resuscitation teams with

the information necessary to implement immediate review

sessions.

Integration With Existing Education

Quality-improvement strategies to improve CPR should

include education to ensure optimal resuscitation team per-

formance. Training in basic or advanced life support provides

foundational knowledge and skills that can be lifesaving and

improve outcomes.151–153 Unfortunately, skills acquired during

these infrequent training programs deteriorate rapidly (within

6–12 months) if not used frequently.154–160 Recent evidence

suggests that frequent short-duration “refreshing” of CPR

skills prevents that decay and improves acquisition and reten-

tion of skills.150,161,162 Therefore, there is increasing interest in

using this as the foundation for maintenance of competence/

certification. Although the various continuous training strat-

egies differ in their advantages, disadvantages, and resource

intensiveness, the expert panel recommends that some form

of continuous training should be a minimum standard for all

CPR CQI programs.

Improved individual healthcare provider and resuscitation

team performance can also be achieved through the use of

simulated resuscitation exercises, or “mock codes.” Use of

these kinds of team-training exercises also helps reinforce

the importance of human factors in resuscitation team func-

tion163 and may prove to be an important systematic program

to improve survival from cardiac arrest.164 Resuscitation train-

ing and education should not be considered a course or a sin-

gle “event” but rather a long-term progression in the ongoing

quest to optimize CPR quality.

Systems Review/Quality Improvement

Every EMS system, hospital, and other professional rescuer

program should have an ongoing CPR CQI program that pro-

vides feedback to the director, managers, and providers. CPR

CQI programs can and should implement systems to acquire

and centrally store metrics of CPR performance. System-wide

performance (which is optimally linked with survival rate)

should be reviewed intermittently, deficiencies identified, and

corrective action implemented. Routinely scheduled hospital

cardiac arrest committee meetings, departmental “morbidity

and mortality” meetings, and EMS quality review meetings

can serve as platforms to discuss selected cases of arrest care

Figure 2. A continuous process evaluates and improves clinical care and generates new guidelines and therapy. Outcome data from

cardiac arrest and periarrest periods are reviewed in a continuous quality-improvement (CQI) process. Research and clinical initiatives

are reviewed periodically in an evidence-based process. Experts then evaluate new therapy and make clinical and educational

recommendations for patient care. The process is repeated, and continual progress and care improvements are generated. ED indicates

emergency department; EMS, emergency medical services; and RRT, rapid response team. *This is an overlap point in the cycle. That is,

data come from outcomes databases (shown on the right) and go into registries and national databases (shown on the left).

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10 Circulation July 23, 2013

in detail and provide opportunities for feedback and reinforce-

ment of quality goals. For example, time to first defibrillation

attempt and CCF have both been shown to directly relate to

clinical outcomes and are discrete metrics with clear mean-

ing and opportunities for tracking over months or years. Over

time, lessons learned from both a system-wide evaluation

of performance and individual performance of teams from

debriefing can provide invaluable objective feedback to sys-

tems to pinpoint opportunities for targeted training. The deliv-

ery of these messages needs to be consistent with the culture

of the organization.

A number of large data collection initiatives have enriched

clinical resuscitation science and represent opportunities

to improve CQI processes. Similarly, the integration of

local CQI processes, policies, and education through reg-

istries and national databases helps determine and drive

regional, national, and global agendas (Figure 2). Get With

The Guidelines-Resuscitation is an AHA-sponsored registry

representing >250 000 in-hospital cardiac arrest events. The

Cardiac Arrest Registry to Enhance Survival (CARES), estab-

lished by the Centers for Disease Control and Prevention, col-

lects national data on out-of-hospital cardiac arrest. The ROC

has developed Epistry, a large database of out-of-hospital car-

diac arrest events, which includes granular CPR quality met-

rics. A consortium of the European Resuscitation Council has

created EuReCa (European Cardiac Arrest Registry), a mul-

tinational, multicultural database for out-of-hospital cardiac

arrest. The value of these registries has been demonstrated

by numerous research studies using registry data to identify

variability in survival, development of standardized mortality

ratios for comparing healthcare settings, and specific resusci-

tation quality deficiencies. In addition, a recent study has sug-

gested that longer participation by hospitals in Get With The

Guidelines-Resuscitation is associated with improvements in

rates of survival from in-hospital cardiac arrest over time.165

Hospitals and EMS systems are strongly encouraged to par-

ticipate in these collaborative registry programs. The costs of

participation are modest and the potential benefits large. Not

taking advantage of these mechanisms for data collection and

benchmarking means that improved quality of care and sur-

vival will remain elusive.

Many existing obstacles to a systematic improvement in

CPR quality are related to ease of data capture from monitor-

ing systems for systematic review. Currently, most monitors

capable of measuring mechanical parameters of CPR provide

feedback to optimize performance during cardiac arrest, and

some may provide for event review immediately afterward,

but none readily lend themselves to systems review. In cur-

rent practice, for example, most CPR-recording defibrillators

require a manual downloading process. A number of chal-

lenges remain for CQI tools that are not limited to integration

of these data into workflow and processing. Although many

devices now exist to capture CPR quality metrics, robust wire-

less methods to transmit these data need to be less expensive

and more widespread. To make CPR quality data collection

routine, these processes need to be much more effortless. We

Table 2. Final Recommendations

1. High-quality CPR should be recognized as the foundation on which all other resuscitative efforts are built. Target CPR performance metrics include

a. CCF >80%

b. Compression rate of 100 to 120/min

c. Compression depth of ≥50 mm in adults with no residual leaning

i. (At least one third the anterior-posterior dimension of the chest in infants and children)

d. Avoid excessive ventilation

i. (Only minimal chest rise and a rate of <12 breaths/min)

2. At every cardiac arrest attended by professional rescuers

a. Use at least 1 modality of monitoring the team’s CPR performance

b. Depending on available resources, use at least 1 modality of monitoring the patient’s physiological response to resuscitative efforts

c. Continually adjust resuscitative efforts based on the patient’s physiological response

3. Resuscitation teams should coordinate efforts to optimize CPR during cardiac arrest by

a. Starting compressions rapidly and optimizing CPR performance early

b. Making sure that a team leader oversees the effort and delegates effectively to ensure rapid and optimal CPR performance

c. Maintaining optimal CPR delivery while integrating advanced care and transport

4. Systems of care (EMS system, hospital, and other professional rescuer programs) should

a. Determine a coordinated code team response with specific role responsibilities to ensure that high-quality CPR is delivered during the entire event

b. Capture CPR performance data in every cardiac arrest and use an ongoing CPR CQI program to optimize future resuscitative efforts

c. Implement strategies for continuous improvement in CPR quality and incorporate education, maintenance of competency, and review of arrest characteristics

that include available CPR quality metrics

5. A national system for standardized reporting of CPR quality metrics should be developed:

a. CPR quality metrics should be included and collected in national registries and databases for reviewing, reporting, and conducting research on resuscitation

b. The AHA, appropriate government agencies, and device manufacturers should develop industry standards for interoperable raw data downloads and reporting

from electronic data collected during resuscitation for both quality improvement and research

AHA indicates American Heart Association; CCF, chest compression fraction; CPR, cardiopulmonary resuscitation; CQI, continuous quality improvement;

EMS, emergency medical services.

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Meaney et al Improving CPR Quality 11

encourage manufacturers to work with systems to develop

seamless means of collecting, transmitting, and compiling

resuscitation quality data and linking them to registries to

improve future training and survival from cardiac arrest.

Conclusions

As the science of CPR evolves, we have a tremendous oppor-

tunity to improve CPR performance during resuscitation

events both inside and outside the hospital. Through better

measurement, training, and systems-improvement processes

of CPR quality, we can have a significant impact on survival

from cardiac arrest and eliminate the gap between current and

optimal outcomes. To achieve this goal, the expert panel pro-

poses 5 recommendations (Table 2), as well as future direc-

tions to close existing gaps in knowledge.

Future Directions

The expert panel expressed full consensus that there is a sig-

nificant need to improve the monitoring and quality of CPR

in all settings. Although there is a much better understanding

of CPR, several critical knowledge gaps currently impede the

implementation and widespread dissemination of high-quality

CPR (Table 3). Research focused on these knowledge gaps

will provide the information necessary to advance the delivery

of optimal CPR and ultimately save more lives. Additionally,

we encourage key stakeholders such as professional societ-

ies, manufacturers, and appropriate government agencies to

work with systems to develop seamless means of collecting

and compiling resuscitation quality data and to link them to

registries to improve future training and rates of survival from

cardiac arrest.

Acknowledgments

We thank the following individuals for their collaborations on the state

of knowledge summary development and summit participation. Along

with the writing group, the CPR Quality Summit investigators include

Lance B. Becker, M. Allen McCullough, Robert M. Sutton, Dana E.

Niles, Mark Venuti, Mary Fran Hazinski, Jose G. Cabanas, Thomas

Rea, Andrew Travers, Elizabeth A. Hunt, Graham Nichol, Michael A.

Rosen, Kathy Duncan, Vinay M. Nadkarni, and Michael R. Sayre.

Sources of Funding

Unrestricted funding for the CPR Quality Summit was provided by

the CPR Improvement Working Group (Laerdal Medical, Philips

Healthcare, and ZOLL Medical Corporation).

Table 3. Future Directions Needed to Improve CPR Quality: Research and Development

Research

• To determine the optimal targets for CPR characteristics (CCF, compression rate and depth, lean, and ventilation), as well as their relative importance to patient

outcome

• To determine the effect of a victim’s age and cause of arrest on optimal CPR characteristics (especially initiation and method of ventilation)

• To further characterize the relationships between individual CPR characteristics

• To further characterize which CPR characteristics and relationships between them are time dependent

• To determine the impact of the variability during the arrest of CPR characteristics (especially CCF and depth) on patient outcome

• To clarify whether ventilation characteristics (time-, pressure-, volume-based parameters) during CPR impact patient outcome

• To determine optimal titration of hemodynamic and etco2 monitoring during human CPR

• To determine whether etco2 monitoring of a noninvasive airway is a reliable and useful monitor of CPR quality

• To determine optimal relationship between preshock CPR characteristics (ie, depth, pause) and ROSC/survival

• To determine the optimal number of rescuers and the effect of rescuer characteristics on CPR quality and patient outcome

• To further characterize the impact of provider fatigue and recovery on patient outcome

• To determine the impact of work environment, training environment, and provider characteristics on CPR performance and patient survival

• To clarify methods of integration of CPR training into advanced courses and continuing maintenance of competency

• To determine the method of education, as well as its timing and location, at a system level to ensure optimal CPR performance and patient outcome

• To develop a global CPR metric that can be used to measure and optimize educational and systems improvement processes

Development

• To standardize the reporting of CPR quality and the integration of these data with existing systems improvement processes and registries

• To develop a device with the ability to measure and monitor CPR quality during training and delivered in real events and integrate it with existing quality

improvement and registries

• To develop optimal CPR systems improvement processes that provide reliable, automated reporting of CPR quality parameters with the capacity for continuous

CPR quality monitoring in all healthcare systems

• To develop feedback technology that prioritizes feedback in an optimal manner (eg, correct weighting and prioritization of the CPR characteristics themselves)

• To develop a more reliable, inexpensive, noninvasive physiological monitor that will increase our ability to optimize CPR for individual victims of cardiac arrest

• To develop training equipment that provides rescuers with robust skills to readily and reliably provide quality CPR

• To develop improved mechanical systems of monitoring CPR, including consistent and reliable capture of ventilation rate, tidal volume, inspiratory pressure, and

duration, as well as complete chest recoil

CCF indicates chest compression fraction; CPR, cardiopulmonary resuscitation; and ROSC, return of spontaneous circulation.

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12 Circulation July 23, 2013

Writing Group Disclosures

Writing

Group

Member Employment Research Grant

Other Research

Support

Speakers’ Bureau/

Honoraria Ownership Interest

Consultant/

Advisory Board Other

Peter A.

Meaney

The University of

Pennsylvania

None None None None None Expert witness:

Serve as medical

expert reviewer

for medical issues

not pertaining to

CPR*

Bentley J.

Bobrow

University of

Arizona; Arizona

Department of

Health Services;

Maricopa Medical

Center

Principal Investigator for

institutional grant to the

University of Arizona from

Medtronic Foundation for

implementing statewide

system of cardiac care†;

NIH funding to study

traumatic brain injury:

1R01NS071049-01A1

(Adults)

3R01NS071049-S1

(EPIC4Kids)†

None None None None None

Benjamin S.

Abella

University of

Pennsylvania

Medtronic Foundation:

project on cardiac arrest

outcomes; payment to

institution†; Doris Duke

Foundation: project on

postresuscitation injury;

payment to institution†;

NIH NHLBI R18: project on

CPR training of lay public;

payment to institution†;

Philips Healthcare: project

on CPR hemodynamics

and quality; payment

to institution†; Stryker

Medical: postarrest care;

payment to institution†

None Medivance: honoraria

for lectures pertaining to

hypothermia after arrest*

Resuscor, a

company focused

on healthcare

provider education

in resuscitation

science: ownership

stake*

HeartSine

Corp: advisory

board role to

evaluate AED

development*;

Velomedix Corp:

postarrest care*

None

Tom P.

Aufderheide

Medical College of

Wisconsin

NHLBI: Resuscitation

Outcomes Consortium;

money comes to institution,

not to me directly†;

NHLBI: Immediate

Trial; money comes

to institution†; NHLBI:

ResQTrial; money comes

to institution†; NINDS:

Neurological Emergency

Treatment Trials (NETT)

Network; money comes to

institution†

Zoll Medical:

software provided

directly from

Zoll Medical

to Milwaukee

County

Emergency

Medical Services

to complete

research trials for

the Resuscitation

Outcomes

Consortium and

Immediate Trials†

None None President,

Citizen CPR

Foundation

(volunteer)*;

Secretary, Take

Heart America

(volunteer)*;

Medtronic paid

consultant;

consultant on an

acute MI trial;

money went to

my institution;

discontinued

consultant

position

November

2010*

National American

Heart Association

volunteer on

Basic Life Support

Subcommittee

and Research

Working Group*;

As a member of

the Institute of

Medicine (IOM)

and a member of

the AHA Research

Working Group,

works with both

institutions to

generate funding

for an IOM report

on cardiac arrest

(volunteer)*

(Continued)

Disclosures

by guest on January 16, 2018http://circ.ahajournals.org/Downloaded from

Meaney et al Improving CPR Quality 13

Writing Group Disclosures, Continued

Writing

Group

Member Employment Research Grant

Other Research

Support

Speakers’ Bureau/

Honoraria Ownership Interest

Consultant/

Advisory Board Other

Robert A.

Berg

University of

Pennsylvania

Perelman School

of Medicine

None None Society of Critical Care

Medicine’s 2012 Asmund

S. Laerdal Memorial

Lecture Award for

outstanding career as a

resuscitation scientist*

None None None

Farhan

Bhanji

Montreal Children’s

Hospital,

McGill University

None None None None None None

Jim

Christenson

University of British

Columbia, Faculty

of Medicine

Resuscitation Outcomes

Consortium group grant

funded until 2016 on CPR

quality; has published

a paper on chest

compression fraction and

its relationship to survival

and is coauthor on several

papers evaluating various

potential aspects of CPR

quality†

None None None None None

Allan R. de

Caen

Self-employed None None None None None None

Dana P.

Edelson

University of

Chicago

Philips Healthcare: funds

paid to institution for

projects on CPR quality and

hemodynamics;

Laerdal Medical: funds paid

to institution for piloting

new Basic Life Support

training†; NIH NHLBI:

funds paid to institution for

strategies to prevent and

predict in-hospital cardiac

arrests†

None None Quant HC: Develops

products for risk

stratification

of hospitalized

patients†

CARES Advisory

Council:

Member*;

Sudden

Cardiac Arrest

Foundation

Board of

Directors:

Member*;

FIERCE

Certification

Advisory

Council:

Member*

Monica E.

Kleinman

Children’s Hospital

Anesthesia

Foundation

None None None None None Expert witness:

Review of

medical-legal

cases on behalf of

defendants*

Marion

Leary

University of

Pennsylvania

None None Speaking honoraria a few

years ago from Philips

Healthcare*

None Have reviewed

devices

for Philips

Healthcare

and Laerdal

surrounding CPR

quality devices,

neither for any

money*

Philips Healthcare

has given

research group

QCPR devices to

use for research*

(Continued)

by guest on January 16, 2018http://circ.ahajournals.org/Downloaded from

14 Circulation July 23, 2013

Writing Group Disclosures, Continued

Writing

Group

Member Employment Research Grant

Other Research

Support

Speakers’ Bureau/

Honoraria Ownership Interest

Consultant/

Advisory Board Other

Mary E.

Mancini

The University of

Texas at Arlington

None None Received honoraria for

keynote speeches at

national professional

meetings such as

National League for

Nursing Education

Summit on Nursing

education. Topics

included the importance

of maintenance of

competency and

simulation; no long-term

agreements to provide

services related to a

speakers’ bureau.*

No personal financial

interest but named

on a patent for CPR

device. University

will receive the

royalty if and

when the device is

commercialized.*

Serves on an

advisory board

for an LWW

nursing product

in development

that will support

nursing students

in developing

critical thinking

skills; one

situation to be

covered is care

of the patient

with a cardiac

arrest.*

None

Venu Menon Cleveland Clinic None None None None None None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the

Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (1) the person

receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (2) the person owns 5% or more of the voting stock or share of

the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding

definition.

*Modest.

†Significant.

Reviewer Disclosures

Reviewer Employment

Research

Grant

Other Research

Support

Speakers’

Bureau/Honoraria

Expert

Witness

Ownership

Interest

Consultant/

Advisory Board Other

Sheldon

Cheskes

Sunnybrook Center for

Prehospital Medicine, Canada

None COPI Toronto site

(Resuscitation

Outcomes

Consortium)†

None None None None None

Gavin

Perkins

Warwick Medical School

and Heart of England NHS

Foundation Trust, United

Kingdom

NIH (money

paid to

institution)†

None None None None None None

Elizabeth H.

Sinz

Penn State Hershey Medical

Center

None None None None None None AHA, Associate

Science Editor

(money paid to

institution)†

Kjetil Sunde University of Oslo, Norway None None None None None None None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure

Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $10 000 or more during

any 12-month period, or 5% or more of the person’s gross income; or (2) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more

of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

†Significant.

by guest on January 16, 2018http://circ.ahajournals.org/Downloaded from

Meaney et al Improving CPR Quality 15

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Peter A. Meaney, Bentley J. Bobrow, Mary E. Mancini, Jim Christenson, Allan R. de Caen,

Hospital: A Consensus Statement From the American Heart Association

CPR Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the

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