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5 Reasons Why Real-Time Feedback Can Make the Difference

CPR Good to Great

Ask "Why" Five Times

The Institute for Healthcare Improvement (IHI) recommends that when a problem presents itself, ask "Why did this happen?" again and again until you reach the root cause.1

When it comes to problems with CPR performance, you might find that your "Why?" trail leads you to a fundamental root cause: lack of real-time feedback during CPR.

Hospitals treat 209,000 cardiac arrests annually with an adult survival rate of 24.8%. Emergency Medical Services treat 350,000 cardiac arrests annually with a survival rate of 12%.2

King County EMS is a shining example of an organization who addressed their "Why?". Their team incorporated real-time feedback during CPR and has since achieved survival rates exceeding 60% - five times the national average in pre-hospital care.

In this article, we share five reasons why real-time feedback can help providers and their organizations go from good to great in delivering CPR.

Those who deliver the best CPR results employ real-time feedback as a means to:

  1. Improve defibrillation success
  2. Maximize perfusion pressure
  3. Adjust for chest stiffness
  4. Ensure engagement and ownership
  5. Continuously improve quality

1. Defibrillation Success

The longer your pre-shock pauses and the shallower your chest compressions, the less likely you will be to achieve defibrillation success. This, of course, applies to a shockable rhythm, VF (ventricular fibrillation) and VT (pulseless ventricular tachycardia).

This finding comes from a study which concluded that each 5 mm increase in compression depth and each 5 second decrease in pre-shock pause shows a doubled increase in the likelihood of shock success after adjusting for arrest location, age, sex and time to shock.3 However, today’s technology, capable of sensing compression rate and depth, has shown that frequent pauses and shallow compression depth are common in clinical practice.3

The reasons for this may be:
  1. Technique
  2. Stress
  3. Hand hygiene compliance
  4. Loss of situational awareness

Real-time feedback can be used to moderate those factors by guiding a CPR provider at the time those factors start to play their destructive role.

2. Maximizing Perfusion Pressure

Maximizing Coronary Perfusion Pressure (CPP) is the key to patient survival until defibrillation is available. A provider must perform CPR in a way presumed to maximize CPP, the part of normal blood pressure that is specifically responsible for coronary blood flow.

According to the American Heart Association (AHA), monitoring of CPR quality is arguably one of the most significant advances in resuscitation practice in the past 20 years.
The AHA spells out five metrics that better hemodynamics and human survival.4
  1. Chest compression fraction: the proportion of time chest compressions are performed during a cardiac arrest must be: >80%
  2. Chest compression rate: between 100–120 compressions per minute
  3. Chest compression depth: 2–2.4 inches for adults and adolescents
  4. Chest recoil: No residual leaning
  5. Ventilation: Less than 12 breaths per minute, minimal chest rise

Real-time feedback can help CPR providers zero in on the best performance possible to ensure CPR success.

3. Every Patient's Chest is Different

Every chest resistance is different, based on the patient's:

  • 1. Age
  • 2. Gender
  • 3. Physiology

According to a study by the AHA in 2006, rescuers often do not compress the chest deeply enough despite recommendations4. Not only did the study validate that every patient's chest resistance is different, it confirmed that chest stiffness decreases significantly with an increasing number of compressions performed during CPR.4 In 2006, there was no upper limit on compression depth. Post - 2015 AHA Guidelines, there is: 2-2.4 inches for adults and adolescents.

Given that real-time feedback is now a readily available technology, achieving the right compression depth and setting the stage for defibrillation success should not be a guessing game. If you or your colleagues have ever felt like it is a guessing game, introducing real-time feedback into your program can help to eliminate that feeling.

4. Autonomy, Not Autopilot

You've likely heard or used the phrase, "I'm not in the loop." This expression comes from the U.S. Air Force concept of a "control loop" known as the OODA loop. When a pilot says he or she is "out of the loop," it means the pilot can no longer observe, orient, decide, and/or act, when flying on autopilot, for example.

Practitioner or pilot, both are high stakes roles in which autonomy and ownership are critical to success. Real-time feedback by its nature gives practitioners little choice but to be engaged in the OODA loop, which improves situational awareness, team performance, and individual attention to detail during CPR.

5. Continuous Quality Improvement

The AHA recommends every EMS system, hospital, and other professional rescuer program should have an ongoing CPR CQI (Continuous Quality Improvement) program that provides feedback to the director, managers, and providers.

This kind of program gives providers an opportunity to focus on a long-term vision with long-term goals. Maximizing performance on the five key metrics of quality CPR becomes not only critical to each individual patient case but to the overall success and esprit of the organization.


Real-time feedback can help you create better conditions for defibrillation success, optimized hemodynamics, optimal compressions, provider ownership, and most importantly continuous improvement. Real-time feedback can give you the means to face possible current errors in your performance, but also the assurance that you can and will improve.


  1. Ask “Why” Five Times to Get to the Root Cause. (n.d.). Retrieved May 11, 2017, from ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx
  2. Heart Disease and Stroke Statistics - 2013 Update . (n.d.). Retrieved May 11, 2017, from CPRAndECC/General/UCM_477263_Cardiac-Arrest-Statistics.jsp
  3. Edelson, D. P., Abella, B. S., Kramer-Johansen, J., Wik, L., Myklebust, H., Barry, A. M., . . . Becker, L. B. (2006). Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation,71(2), 137-145. doi:10.1016/j. resuscitation.2006.04.008
  4. Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., Caen, A. R., Bhanji, F., . . . Leary, M. (2013). Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital: A Consensus Statement From the American Heart Association. Circulation,128(4), 417-435. doi:10.1161/cir.0b013e31829d8654
  5. Tomlinson, A., Nysaether, J., Kramer-Johansen, J., Steen, P., & Dorph, E. (2007). Compression force–depth relationship during out-of-hospital cardiopulmonary resuscitation. Resuscitation,72(3), 364-370. doi:10.1016/j.resuscitation.2006.07.017

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