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5 steps to delivering high-quality CPR

Make sure each of your service’s cardiac arrest patients get the best chance of survival by prioritizing high-quality CPR in training and in practice


High-quality CPR has continually received strong endorsements in the last few revisions of the AHA CPR guidelines.

Photo/Rama via Wikimedia Commons, CC-By-SA 2.0 FR

Every five years, EMS providers and other healthcare providers involved in cardiac arrest resuscitation eagerly await a new version of the American Heart Association CPR and emergency cardiovascular care guidelines. I have been fortunate to see several revisions of the AHA CPR guidelines over my career and clearly recall some big changes including the rise and fall of:

  • Intracardiac epi
  • High-dose epi
  • Bretylium
  • Vasopressin
  • Stacked shocks
  • Therapeutic hypothermia

And don’t even get me started on the changes in the adult, child and infant compression-to-ventilation ratios.

It is important to note, however, that high-quality CPR has continually received strong endorsements in the last few revisions of the AHA CPR guidelines. While many of the therapies and medications we use are still subject to off-again, on-again support from the researchers, the recommendations to make good compressions a core part of resuscitation have stayed basically the same the last few revisions, including the 2020 AHA CPR Guidelines.

It is almost a shame it took us this long to get to this point. In some ways we knew it all along. My introduction to EMS and cardiac arrest care came in the late 1970s. My mother was an EMT and CPR instructor, and participated in fundraising CPR-marathons in the local mall. They laid out a row of recording Resusci Annes and taught CPR to everyone that walked by. Teams of providers also competed to see who could do quality CPR the longest. The manikins had a little light console that told you if you were compressing in the right spot and at the right depth. The units would also print out a graphic recording of the compressions so the rate could be calculated. Maybe we didn’t have the research to tie high-quality CPR to better outcomes at the time, but we knew it was the right thing to do.

Now, 40 years later, high-quality CPR (HQ-CPR) is firmly planted as a critical component of resuscitation. Here are five tips to help you make sure each of your service’s cardiac arrest patients get the best chance of survival.

1. Perform full cycles of CPR when practicing codes

We have all done it. Start with a few good compressions and then lean back on your heals, giving “soft” CPR while the others do airway, ECG, IV and medications. Kneeling on the floor is not comfortable and it is pretty tiring to do real compressions. Challenge yourself and your peers to do real compressions for a full two minutes. It is a great way to demonstrate how important it is to change out compressors regularly.

2. Appoint a supervisor or HQ-CPR monitor

We know it is a best practice to have a designated person in charge of the resuscitation. Ideally, that person can stand back, get the big picture, and monitor all aspects of the response, but in many cases, we just do not have enough crew members to do that.

At a minimum, one crew member should be appointed to run the checklists and make sure that the protocols are followed. This person should also be charged with ensuring high-quality CPR and regular compressor changes.

3. Everyone can do compressions

Do not limit the duty of performing compressions to the people with a Star of Life on their uniform. Not only are firefighters, law enforcement officers, security officers and many others trained to do CPR, anyone can be given just-in-time training and put in the role. With a little coaching and supervision, even bystanders can be cycled into the rotation to limit exhaustion.

While some members of the onlooking public will be too shaken by the situation to help, many others will be happy to do what they can to help. Put them to work doing short rounds of compressions while you tend to other resuscitation duties.

4. Use compression quality monitoring technology

Some of today’s multipurpose patient monitors offer technology to monitor compressions for depth and rate. Stand-alone products, such as CPR pucks, may also be used to remind providers to compress deeper, allow full recoil or minimize pauses. Use of them takes a little practice but allowing them to coach us through a long cardiac arrest case can really improve compression quality.

Incorporate the devices into you protocols and use them during CPR training as well as real cases.

5. Everyone likes a little competition

EMS providers and firefighters tend to have a bit of a competitive nature to them. This can be demonstrated by the popularity of EMS competitions at conferences and the wide range of interagency softball, bowling and basketball tournaments that occur in communities every year.

Take advantage of that competitive spirit and challenge crews to CPR contests. Whether it be crew versus crew, station versus station or EMS versus fire, give the opportunity for someone to take home bragging rights for compression quality, shortest interruptions or overall cardiac arrest case management.

Do whatever it takes. Get creative and incorporate measures to make HQ-CPR a standard part of your cardiac arrest care. Quality CPR matters and it can save a life.

Stay safe out there.

Read next: Updated AHA CPR guidelines address overdoses, technology, cardiac arrest recovery

Michael Fraley has over 30 years of experience in EMS in a wide range of roles, including flight paramedic, EMS coordinator, service director and educator. Fraley began his career in EMS while earning a bachelor’s degree at Texas A&M University. He also earned a BA in business administration from Lakeland College. When not working as a paramedic or the coordinator of a regional trauma advisory council, Michael serves as a public safety diver and SCUBA instructor in northern Wisconsin.