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2020 AHA Guidelines for CPR and ECC: Resuscitation Education Science & Systems of Care

RQI PartnersEvery 5 years, the American Heart Association (AHA) revises the recommendations, or Guidelines, for Emergency Cardiovascular Care (ECC), including CPR. Here is a summary of some of the key issues and major changes for Resuscitation Education Science and Systems of Care. These were released on October 21, 2020, and will be implemented into AHA classes over the next few months.

Resuscitation Education Science 

- Effective education is a key variable in improving cardiac arrest survival.

- Without effective education, lay rescuers and healthcare providers may not consistently apply the science supporting evidence-based cardiac arrest treatment. 

- Evidence-based instructional design is critical to improving provider performance and patient-related outcomes from cardiac arrest.  

Summary of Key Issues and Major Changes 

- The use of deliberate practice and mastery learning during life support training, and incorporating repetition with feedback and minimum passing standards, can improve skill acquisition. 

- Booster training (ie, brief retraining sessions) should be added to massed learning (ie, traditional course based) to assist with retention of CPR skills.

- For laypersons, self-directed training, either alone or in combination with instructor-led training, is recommended to improve willingness and ability to perform CPR. Greater use of self-directed training may remove an obstacle to more widespread training of laypersons in CPR. 

- Middle school– and high school–age  children should be trained to provide  high-quality CPR. 

- Laypersons should receive training in how to respond to victims of opioid overdose, including the administration of naloxone. 

- Bystander CPR training should target specific socioeconomic, racial, and ethnic populations who have historically exhibited lower rates of bystander CPR. 

- CPR training should address gender-related barriers to improve rates of bystander CPR performed on women.

- EMS systems should monitor how much exposure their providers receive in treating cardiac arrest victims. 

- All healthcare providers should complete an adult ACLS course or its equivalent. 

- Use of CPR training, mass training, CPR awareness campaigns, and hands-only CPR promotion should continue on a widespread basis to improve willingness to provide CPR to cardiac arrest victims, increase the prevalence of bystander CPR, and improve outcomes from OHCA. 

Deliberate Practice and Mastery Learning 

- Incorporating deliberate practice and mastery learning model into basic or advanced life support courses may be considered for improving skill acquisition and performance. 

- Deliberate practice is a training approach where students are given a discrete goal to achieve, immediate feedback on their performance, and ample time for repetition to improve performance. Mastery learning is defined as the use of deliberate  practice training and testing that includes a set of criteria to define a specific passing standard, which implies mastery of the tasks being learned.  

Booster Training and Spaced Learning 

- Implement booster sessions when utilizing a massed-learning approach for resuscitation training. 

- Addition of booster training sessions (brief, frequent sessions focused on repetition of prior content to resuscitation courses) improves the retention of CPR skills.  

Lay Rescuer Training 

- A combination of self-instruction and instructor-led teaching with hands-on training is  recommended as an alternative to instructor-led courses for lay rescuers. If instructor-led training is not available, self-directed training is recommended  for lay rescuers. 

- Train middle and high school–age children in how to perform high-quality CPR. 

Opioid Overdose Training for Lay Rescuers 

- Lay rescuers should receive training in responding to opioid overdose, including provision of naloxone. 

- Deaths from opioid overdose in the US have more than doubled in the past decade. 

- Targeted resuscitation training for opioid users and their families and friends is associated with higher rates of naloxone administration in witnessed overdoses.  

Disparities in Education 

- Tailor layperson CPR training to specific racial and ethnic populations and neighborhoods in the United States. 

- Address barriers to bystander CPR for female victims through educational training  and public awareness efforts. 
- Communities with low socio-economic status and those with predominantly Black and Hispanic populations have lower rates of bystander CPR and CPR training. 

- Women are also less likely to receive bystander CPR, which may be because bystanders fear injuring female victims or being accused of inappropriate touching.  

EMS Practitioner Experience and Exposure to Out-of-Hospital Cardiac Arrest 

- EMS systems should monitor clinical personnel’s exposure to resuscitation to ensure treating teams have members competent in managing cardiac arrest cases. 

- EMS provider exposure to cardiac arrest cases is associated with improved patient outcomes, including rates of ROSC and survival. 

- EMS systems monitor provider exposure and develop strategies to address low exposure. 

ACLS Course Participation 

- All health care professionals should take an ACLS course or equivalent training. 

- Studies show that resuscitation teams with 1+ team members trained in ACLS have better patient outcomes.  

Willingness to Perform Bystander CPR 

- Increase bystander willingness to perform CPR through CPR training, mass CPR  training, CPR awareness initiatives, and  promotion of Hands-Only CPR. 

Systems of Care 

- Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations. 

- Willing bystanders, property owners who maintain AEDs, emergency service  telecommunicators, and BLS and ALS providers working within EMS systems all contribute to successful resuscitation from OHCA. 

- Within hospitals, the work of physicians, nurses, respiratory therapists, pharmacists, and other professionals supports resuscitation outcomes.  

- Successful resuscitation depends on the contributions of equipment manufacturers, pharmaceutical companies, resuscitation instructors, guidelines developers, and many others. 

- Long term survivorship requires support from family and professional caregivers,  including experts in cognitive, physical, and psychological rehabilitation and  recovery. 

- A systems-wide commitment to quality improvement at every level of care is essential to achieving successful outcomes. 

Summary of Key Issues and Major Changes 

- Recovery continues long after the initial hospitalization and is a critical component of the resuscitation Chains of Survival. 

- Efforts to support the ability and willingness of the members of the general public to perform CPR and use an AED improve resuscitation  outcomes in communities.

- Use mobile phone technology to alert trained lay rescuers of events that require CPR are promising and deserve more study. 

- Emergency system telecommunicators can instruct bystanders to perform hands-only CPR for adults and children.

- Early warning scoring systems and rapid response teams can prevent cardiac arrest in both pediatric and adult hospitals, but the literature is too varied to understand what components of these systems are associated with benefit.

- Cognitive aids may improve resuscitation performance by untrained laypersons, but in simulation settings, their use delays the start of CPR. More development and study are needed before these systems can be fully endorsed.

- Surprisingly little is known about the effect of cognitive aids on the performance of EMS or hospital based resuscitation teams.

- Although specialized cardiac arrest centers offer protocols and technology not available at all hospitals, the available literature about their impact on resuscitation  outcomes is mixed.

- Team feedback matters. Structured debriefing protocols improve the performance of resuscitation teams in subsequent resuscitation.

- System-wide feedback matters. Implementing structured data collection and review improves resuscitation processes and survival  both inside and outside the hospital. 

Using Mobile Devices to Summon Rescuers 

- Use mobile phone technology by emergency dispatch systems to alert willing bystanders to nearby events that may require CPR or AED use is reasonable. 

Data Registries to Improve System Performance 

- Organizations that treat cardiac arrest patients should collect processes-of-care data and  outcomes. 

For more information about the 2020 AHA Guidelines, please review our other blogs or visit

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