What is High-Performance CPR and Why Is It Important?

In its recent annual report, the American Heart Association (AHA) noted that out-of-hospital cardiac arrest (OHCA) continues to be a common and deadly problem in the U.S. Of the more than 356,000 OHCA occurrences annually, almost 90% are fatal. Even in the case of EMS-assessed non-traumatic OHCA – which is around 1,000 people every day – survival to hospital discharge is still only around 10%.

While cardiopulmonary resuscitation (CPR) has existed since 1960, the impact of CPR on survival from sudden cardiac arrest (SCA) has hovered around 10-14%. Using a combination of external chest compressions and forced breaths, CPR delivers a limited supply of oxygen to body tissue and simulates heart function until help can arrive or until the patient arrives at the ED. Moments matter for SCA incidents because for each minute a person is in cardiac arrest, there is a 10% decrease in the chance for survival.

However, recent studies have shown that an increased focus on the quality of CPR delivered during an OHCA can dramatically increase survival up to 40-60% in some cases. For decades, performing CPR included mouth-to-mouth resuscitation in addition to chest compressions; experts now advise chest compressions alone can keep the heart pumping and maintain blood flow until help arrives. This new approach that focuses on more accurately delivering specific CPR protocols has been termed “high-performance CPR” (also known as “high-quality CPR”).

What is High-Performance CPR?

High-performance CPR improves oxygen and blood circulation in the patient’s body while emergency medical personnel are on the way. Ideally an automated external defibrillator (AED) will also be used to administer an electrical shock through the heart tissue. The main areas of focus of high-performance CPR include performing chest compressions at the optimal depth and rate, minimizing compression interruptions, and avoiding leaning on the patient’s chest.

Best Practices for High-Performance CPR

When an OHCA occurs, bystanders need to act fast. In fact, the American Red Cross recommends beginning CPR within 10 seconds of the suspected SCA (for example, if the person is not responsive, suddenly collapses, has no pulse, is not breathing or is only gasping). CPR should only be stopped if a pulse is found or if the individual regains consciousness; if he or she no longer needs CPR, their pulse should be monitored every two minutes.

Once determined that CPR is needed, the first step is to have another bystander call 911 and look for an automated external defibrillator (AED) device nearby. CPR should be started immediately, and the following guidelines can help improve the victim’s chances of favorable outcome:

• Push Hard: High-performance CPR is best suited for adults and teens (conventional CPR is still considered best for children). Press hard and fast in the center of the chest, down at least 2 inches with full bodyweight. People are often nervous about pushing down hard enough, but any minimal injuries to the patient are less important than their survival. Blood is being pushed through the entire body, and it takes a significant amount of pressure.
• Push Fast: The optimum rate of compression is 100 to 120 beats per minute. The American Red Cross suggests singing one of the following songs internally to get the correct tempo: “Stayin’ Alive” by the Bee Gees, “Girls Just Want to Have Fun” by Cyndi Lauper, or “Should I Stay or Should I Go?” by The Clash.
• Pay Attention: Allow for full chest recoil between compressions and don’t lean on the patient’s chest. The effect of chest recoil in helping blood flow is significant.
• Don’t Stop: It can be tiring to deliver high-performance CPR, so ideally several people are willing to take turns until EMS arrives. However, it’s important to communicate when handing off compressions to avoid any disruption of the tempo. Stopping between compressions can cause an instant decrease in blood pressure, which takes a long time to build up again.
• Utilize the AED: Automated external defibrillators, increasingly more common in public places today, can send an electrical shock through the heart tissue. It’s important to begin CPR right away, so ideally another responder can work on hooking up the AED while the first continues CPR. Read the included instructions. Some AEDs also offer CPR feedback on rate and depth of compressions, as well as audio instructions.
• Avoid Excessive Ventilation: High-performance CPR eliminates rescue breaths because excessive air volume can result in complications that reduce the quality of the effort.

High-Performance CPR Helps Improve Survival Rates

As technology continues to improve and more focus is turned to optimizing CPR guidelines and techniques, survival rates of OHCA will hopefully increase as well. While studies show that only 46% of SCA victims receive CPR from bystanders, these new recommendations for hands-only, high-performance CPR may help laypeople stabilize victims more effectively until trained professionals can arrive.

Similarly, high-performance CPR is also gaining adoption in prehospital emergency care and nursing homes. New technologies are allowing data to be recorded regarding quality of compressions (rate and depth), and offer instant feedback, allowing a provider to improve CPR efforts in real time. This information can later be anonymized and submitted to national databases to assist in research efforts and used to improve agency performance.

Just like any medical protocol, recommendations and guidelines for CPR must be adapted and improved as more is learned and demographics change. By implementing high-performance CPR best practices, members of the public and medical professionals alike can help drive down the mortality rate of OHCA.