Survival from out-of-hospital cardiac arrest (OHCA) continues to be dismal in many EMS systems around the world.1 Is this actually true, or is it merely an often-used opening line to thousands of papers published annually on OHCA survival?

Evidence from many communities suggests otherwise. In fact, in many jurisdictions, survival from OHCA has improved dramatically, impacting many lives.2–5

So, what’s the difference between some jurisdictions and others when it comes to OHCA survival? Are there common themes that others can learn from in improving their own survival rates?

One of the common themes we see in areas with higher survival rates is a focus on providing high-quality CPR to patients in OHCA. Compression rate, depth, shock pause duration, release velocity and the use of CPR feedback have all been associated with improved outcomes and are highlighted repeatedly in the 2015 AHA/ILCOR guidelines as crucial factors to improving outcomes from OHCA.6–13 (See Figure 1.)

Yet surprisingly, many systems around the world still fail to measure these metrics, despite the widespread availability of technology that makes this process both simple and inexpensive. But many systems choose to find any number of reasons, such as cost, workload and failure to have resources to implement these systems, as an excuse not to measure CPR quality, which is truly a shame.

The well-known adage of “if you don’t measure it, you can’t improve it,” has never been more appropriate than it is today. The recommendations from the Take Heart America conference will go a long way in ensuring that every EMS system in North America has the capability to measure CPR quality in all cases of cardiac arrest, while also putting into place quality assurance programs focused on improving CPR quality for all. Focusing on implementing real-time CPR feedback on a global basis will go a long way in attaining this goal.

The future of cardiac arrest research is full of new concepts and research into new strategies focused on improving OHCA survival. Whether we speak about ACD+ITD CPR, ECMO, double sequential external defibrillation, or alternative drug therapies for patients in cardiac arrest of a variety of etiologies, what remains clear is that none are effective without high-quality CPR.14–17

The previously demonstrated interaction between interventions and high-quality CPR informs us that without improved CPR quality, even the greatest of ideas will fall flat.18 So let’s all, as a resuscitation community, increase our focus on improving the quality of CPR around the world. The old adage of “some CPR is better than no CPR at all” must be replaced by “high-quality CPR is the only form of CPR.”


1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics–2015 update: A report from the American Heart Association. Circulation. 2015;131(4):e29–e322.

2. Buick JE, Drennan IR, Scales DC, et al. Improving temporal trends in survival and neurological outcomes after out-of-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 2018;11(1):e003561.

3. Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015; 91:108–115.

4. Grunau B, Kawano T, Dick W, et al. Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006–2016. Resuscitation. 2018;125(4):118–125.

5. Adabag S, Hodgson L, Garcia S, et al. Outcomes of sudden cardiac arrest in a state-wide integrated resuscitation program: Results from the Minnesota Resuscitation Consortium. Resuscitation. 2017;110(1):95–100.

6. Cheskes S, Schmicker RH, Christenson J, et al.  Perishock pause: An independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011;124(1);58–66.

7. Cheskes S, Schmiker RH, Verbeek PR, et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the ROC PRIMED trial. Resuscitation. 2014;85(3):336–342.

8. Idris AH, Guffey D, Aufderheide TP, et al. The relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012;125(24):3004–3012.

9. Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med. 2012;40(4):1192–1198.

10. Idris AH, Guffey  D, Pepe PE, et al. Chest compression rates and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015;43(4):840–848.

11. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241–1247.

12. Bobrow B, Silver A, Stolz U, et al. Chest compression release velocity is independently associated with survival from out-of-hospital cardiac arrest. Resuscitation. 2014;85(Suppl 1):S1–S2.

13. Lin I, Cheng A, Grant VJ, et al. Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers—A randomized controlled trial. Resuscitation. 2018;130:6–12.

14. Plaisance P, Lurie KG, Vicaut E, et al. Evaluation of an impedance threshold device in patients receiving active compression–decompression cardiopulmonary resuscitation for out of hospital cardiac arrest. Resuscitation. 2004;61(3):265–271.

15. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88–94.

16. Cortez E,  Krebs W, Davis J, et al. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. 2016;108:82–86.

17. Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85(10):1337–1341.

18. Yannopoulos D, Aufderheide TP, Abella BS, et al. Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation. 2015;94:106–113.