Cardiac & Resuscitation

Revising Your Protocols to Comply with the 2015 AHA Guidelines

Issue 3 and Volume 41.

The 2015 American Heart Association (AHA) Guidelines Update for CPR and Emergency Cardiovascular Care (ECC) provide an implementation challenge for EMS agencies, big or small. For this revision, the AHA devoted significant effort to thinking about the impact of these guidelines on EMS agencies and the overall system of care outside of the hospital.1

Because of the need to reach a victim of cardiac arrest quickly, almost all EMS agencies partner with other organizations including police, fire, public health, schools and hospitals with the goal of a seamless system optimized to give the victim the best possible shot at survival. The large number of potential rescuers makes the math daunting.

In the Seattle EMS system, we care for about 450 cardiac arrest patients a year out of a total population of 675,000 people. To put that another way, we attempt to resuscitate about 65 victims for every 100,000 people. That number is pretty typical. Most North American EMS systems will fall in the range of attempting to resuscitate 50–80 cardiac arrest victims per 100,000 population, depending on the age distribution in the area.

Our agency has about 1,000 uniformed personnel, yet a cardiac arrest occurs only once or twice a day. This means each four-person fire company crew will, on average, care for only one or two cardiac arrest patients annually.2

Most available research suggests that successful implementation of CPR guidelines in an EMS agency takes 1–2 years. This implementation delay is difficult to overcome given the relative infrequency of resuscitation events.

Training has to fill the gap. Experience has taught us that successful implementation of a resuscitation intervention requires more than one round of training for each person working in an EMS system. Typically, three training events are needed to expect reasonable rescuer performance at stressful cardiac arrest resuscitations.


Recently, the Resuscitation Outcomes Consortium (ROC) published the results of the continuous chest compressions trial.3 The difference in survival to hospital discharge between the two arms of the trial was 0.7%. Many readers were intrigued by these results.

Ignored by most readers is the difference in survival to hospital discharge among the study sites. In one site, survival to hospital discharge was about 3.5%. In another site, hospital discharge survival was almost 19%. This difference isn’t explained by variations in age, bystander CPR or other easily measured variables.4

A key lesson learned is that performance, not protocol, drives survival. Changing your EMS agency’s protocol to comply with the new guidelines could be helpful; however, the large variation in survival among the study sites noted in the ROC trial argues that larger gains can happen by focusing on excellent performance.


Over more than a decade, our system’s cardiac arrest neurologically favorable survival to hospital discharge has slowly improved. This has occurred despite lack of any new medications or a change in response configuration.

What’s made the difference?

The system implemented an organized approach to team training and CPR and cardiac arrest management.

Several of the senior paramedics helped to crystallize the training process as “high-performance CPR.” This approach is freely available online at Videos show a way to implement effective CPR team work for 2-, 3- and 4-person crews.

Other EMS systems have implemented high-performance CPR with dramatic results. Salt Lake City Fire Department implemented a variation on high-performance CPR in September 2011.5 Neurologically favorable survival to hospital discharge for all resuscitation attempts more than doubled from 7.5% to 16%.

By focusing on feedback to crews following resuscitation attempts to increase use of high-performance CPR, EMS leaders in Mesa, Ariz., increased survival to hospital discharge from 9% in 2009 to 14% in 2011.6

The EMS system in the entire state of North Carolina has notched impressive gains in survival following implementation of high-performance CPR training.The Tulsa and Oklahoma City EMS systems have also improved survival significantly.8


When revising your protocols to incorporate the new science in the 2015 AHA Guidelines, make sure your training emphasizes the basics. High-performance CPR incorporates the following principles: chest compression rate between 100 and 120, repetitive training with individual feedback during training to drive home the chest compressions depth of 2–2.4 inches while avoiding leaning, and controlling ventilation with small breaths just sufficient to make the chest rise.

In our system, we use a simple metronome set at 110 beats per minute to ensure our crews keep their compressions in the right range. We teach a three-finger technique to gently squeeze the bag for ventilation to avoid excessive tidal volume. Rescuers learn to “hover” their hands over the chest rather than, “I’m clear, you’re clear, everybody’s clear,” to lessen post-shock pauses in chest compressions.

Our instructors emphasize that BLS owns CPR. The BLS crews learn that paramedics must not be permitted to interfere with quality chest compressions while doing “paramedic stuff ” like endotracheal intubation.

By focusing on these principles of high-performance CPR in your training and performing at least three training sessions in the next year, you’ll see dramatic improvement in survival from cardiac arrest in your community as a direct result of implementing the 2015 AHA Guidelines Update on CPR and ECC.


1. Kronick SL, Kurz MC, Lin S, et al. Part 4: Systems of care and continuous quality improvement: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2): S397–S413.

2. Dyson K, Bray J, Smith K, et al. Paramedic exposure to out-of-hospital cardiac arrest is rare and declining in Victoria, Australia. Resuscitation. 2015;89:93–98.

3. Nichol G, Leroux B, Wang H, et al. Trial of continuous or interrupted Chest compressions during CPR. N Engl J Med. 2015;373(23):2203–2214.

4. Rea TD, Cook AJ, Stiell IG, et al. Predicting survival after out-of-hospital cardiac arrest: Role of the Utstein data elements. Ann Emerg Med. 2010;55(3):249-57.

5. Hopkins C, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc. 2016;5(1).

6. Bobrow B, Vadeboncoeur T, Stolz U, et al. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Ann Emerg Med. 2013;62(1):47–56.e1.

7. Malta Hansen C, Kragholm K, Pearson DA, et al. Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010–2013. JAMA.2015;314(3):255–264.

8. Goodloe JM. Stay on time: A conversation about the importance of count & cadence of chest compressions. JEMS. 2014;39(11):S36–S40.