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key takeaways

  • High-quality CPR improves cardiac arrest outcomes, but it’s difficult for clinicians to evaluate CPR quality accurately on their own.
  • Real-time CPR feedback devices can help clinicians assess CPR quality and make on-the-fly adjustments during a code.
  • Delayed CPR feedback is most useful for additional reinforcement and learning after the code ends.

High-quality cardiopulmonary resuscitation (CPR) is endorsed by the American Heart Association (AHA) and widely accepted as a key component of effective Code Blue Care. But as all responders know, it is easier to understand the concept than to execute it optimally in practice.

That’s why we’re bringing you the CPR quality series: to break down the main components of CPR and offer tips and best practices to help responders improve quality.

First up: CPR feedback. What types of CPR devices are available, how can they help responders improve CPR quality, and what are the key takeaways for hospitals to consider? Keep reading to find out.

High-quality CPR: What is it, why is it so elusive, and how can CPR feedback help?

What is high-quality cpr?

The recommendations for rate and depth have changed over the years, but the current AHA guidelines list the following components of high-quality CPR:

  • Chest compression fraction >80%
  • Compression rate of 100-120/min
  • Compression depth of at least 2 inches in adults and at least one-third the anteroposterior dimension of the chest in infants and children
  • Avoiding excessive ventilation, typically by providing 1 breath every 6 seconds for adults with a secured airway (every 2-3 seconds for infants/children), and 2 breaths for every 30 compressions for patients without a secured airway1

Why does high-quality cpr matter?

  • The guidelines provide a standard reference point for everyone performing CPR.
  • Following these guidelines allows for optimal squeezing of the heart. This ensures that there is blood flow to the brain/other vital organs and refill of the heart.
  • Lastly — and most importantly — it works. Of all the interventions that have been studied in cardiac arrest, two are consistently linked to improved outcomes: early defibrillation for shockable rhythms and high-quality CPR.2

Where does cpr feedback come in?

While it may be easy to understand the components listed in the bullet points above, responders often struggle to execute high-quality CPR during actual codes. There are a few reasons why:

  • Fatigue: CPR is physically demanding and requires enough staff availability to substitute compressors when a clinician tires.
  • Distractions: Even with proper CPR training, there are multiple sources of distraction during an actual code that can hamper optimal execution. This includes bed placement, backboard placement, managing emergency equipment, and more — essentially, all the other logistics responders have to consider in addition to optimal CPR technique.
  • Flawed self-assessment: Lastly, it can be hard for responders to gauge and assess their own performance while performing CPR without any kind of aid. Fortunately, this is where CPR feedback can help.

What types of CPR feedback are available?

Broadly, CPR feedback devices can be grouped into two categories: feedback received after the code (delayed feedback) and real-time feedback.

delayed feedback

For quality assurance, most defibrillators/monitors can provide CPR feedback after the event is over, such as a data download to share with staff during a cold debrief.

Delayed feedback certainly has its place. It’s useful for learning purposes, and it can help clinicians refine their skills to improve for future codes. But it has a crucial drawback: Since the data is not available until after the code ends, clinicians aren’t able to adjust and make improvements in the moment. This is where real-time feedback comes in.

real-time feedback

Real-time feedback comes in many forms. Some defibrillators provide real-time audiovisual feedback. There are also portable devices available that can be placed under the patient or under the responder’s hands on the patient’s chest. Other options include end-tidal carbon dioxide readings, looking at arterial waveforms in response to compressions, or apps that offer metronomes to help responders stay on track with compression rate.

Regardless of the method used, the main benefit of real-time feedback is obvious: It allows responders to make in-the-moment adjustments to improve CPR quality.

Does real-time CPR feedback improve performance?

Of the options, it seems logical that real-time feedback would offer the most value for responders. Let’s look at what the data says:

1. A meta-analysis published in 2014 found that real-time feedback (both with manikins and actual patients) helped clinicians maintain CPR performance within AHA guidelines. Interestingly, however, there was no evidence that this improved performance also improved outcomes.3

2. On the other hand, a more recent 2020 meta-analysis found that there was a positive impact on patient outcomes when using real-time CPR feedback devices. However, these findings were only noted with specific portable devices — not associated with a defibrillator — and authors recommended that additional research be performed.4

3. Lastly, a third study confirmed an important point about high-quality CPR and why it can be difficult to achieve: Healthcare providers have difficulty gauging the quality of their own compressions. Fortunately, the study showed that a combination of just-in-time training (i.e., recent skills reinforcement coupled with direct feedback) with real-time feedback devices helped to support improved CPR skills in the moment.5

Key takeaways

As the section above indicates, further research is needed to help clarify the true impact of real-time CPR feedback — and which specific devices are most useful. In the meantime, here’s what we know now:

  • High-quality CPR works. The better your CPR execution, the greater likelihood of patient survival and recovery.
  • But it’s not easy to execute. In part, this is because it’s challenging for responders to gauge CPR quality in the moment without some kind of aid.
  • The AHA recommends use of real-time audiovisual CPR feedback to improve quality.2

The bottom line: CPR feedback is a valuable tool for responders to use during a code. While real-time feedback shows the most promise, hospitals can still consider both real-time and delayed as part of their larger high-quality CPR strategy. For example, that strategy might look like:

  • CPR training beforehand (both as standalone courses and as part of mock codes)
  • Real-time CPR feedback provided to responders during the code
  • Review of CPR quality afterward (such as during hot debriefs) to optimize reflection, reinforcement, and improvement going forward


Keep learning

Next, read our article on mechanical CPR to learn how its use expanded during the COVID-19 pandemic — and what it might mean for the future of Code Blue care.


  1. American Heart Association. Summary of high-quality CPR components for BLS providers. Available at: Summary of High-Quality CPR Components for BLS Providers (
  2. American Heart Association (2020). Highlights of the 2020 American Heart Association’s guidelines for CPR and ECC. Available at:
  3. Kirkbright S, Finn J, Tohira H, et. al. (2014). Audiovisual feedback device use by health care professionals during CPR: a systematic review and meta-analysis of randomised and non-randomised trials. Resuscitation, 85(4), 460-471.
  4. Wang S-A, Su C-P, Fan H-Y, et. al. (2020). Effects of real-time feedback on cardiopulmonary resuscitation quality on outcomes in adult patients with cardiac arrest: a systematic review and meta-analysis. Resuscitation, 155, 82-90.
  5. Cheng A, Overly F, Kessler D, et. al. (2015). Perception of CPR quality: influence of CPR feedback, just-in-time CPR training and provider role. Resuscitation, 87, 44-50.
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