Maximizing Chest Compression Fraction for Better Outcomes

As a health care professional, you know that every second counts when your patient is in cardiac arrest. The faster you can restore a regular heart rhythm, the better chance your patient has to survive to discharge. Maintaining a high chest compression fraction (CCF) is a critical factor in improving their chances. But how can you increase chest compression fraction during a code?

In this guide, I explore this vital technique and how you can perform it confidently and consistently in your practice. I’ll discuss the evidence that supports working toward a high CCF, as well as some of the emerging CPR technologies to improve CCF.  You’ll be seeing these everywhere soon—if you aren’t already.

What is Chest Compression Fraction (CCF)?

During CPR, chest compression fraction is the time that you actively perform chest compressions—measured as a percentage. Whether you are a single rescuer, a two-person team, or a code blue response unit, chest compressions are not performed for the entire CPR session. Depending on your team size and license, you may have:

• Time to set up monitoring equipment
• Time to check vitals and assess the situation
• Pauses to give breaths
• Airway management
• Handoff between rescuers
• Administering medications
• Administering shock

Imagine you’re a paramedic who has just arrived on the scene of the collapse of an individual at the county fair. You quickly assess your patient who is in cardiac arrest. You then activate CPR protocols with your partner. You start oxygen, hook up the monitor and defibrillation, and begin chest compressions as you follow the ACLS Algorithm for Adult Cardiac Arrest you know so well.

In all, you administer CPR for 10 minutes. However, within this time, you and your partner have only given chest compressions for eight minutes. This is a CCF of 80%. The goal of your emergency response team is to achieve an 80% or higher CCF during a situation like this. Achieving this gives your patient the best possible blood flow to vital organs like the brain and heart.

Why High Chest Compression Fraction is so Important

Your ability to maintain high CCH can directly affect your patient’s outcome during cardiac arrest. Whether you’re performing CPR in the emergency department’s waiting room, patient’s room, the field, or in the racing ambulance, maintaining a high chest compression fraction improves your patient’s likelihood of survival. By how much? Let’s take a look!

The Evidence for High CCF

A meta-analysis reviewed the records of almost 13,000 patients in the US and Canada to determine survival and discharge rates. The included patients with a mean age of 68 (majority male) who had experienced an OHCA (out-of-hospital cardiac arrest) without shock before EMS arrival. Some of the patients had shockable rhythms when EMS arrived, while others did not. The analysis of medical records found the following (NIH.gov):

• The median CCF was 74%, demonstrating an understanding of the importance of high CCF, even if it fell below the 80%
• 25.6% achieved ROSC (return to spontaneous circulation)
• 2.4% survived to discharge, which is notable and in line with other studies on OHCA where bystander CPR with AED is not initiated
• Higher CCF improved the odds of achieving ROSC, but did not increase survival to discharge rates

However, keep in mind they included those with initial non-shockable rhythms. Other studies have shown that initial shockable rhythms have a 200 to 300% higher chance of survival during IHCA (in hospital cardiac arrest) (nature.com). 

Similarly, for OHCA, a study showed a 7.1% chance of survival to discharge with initial shockable rhythm compared to 0.4% for non-shockable (Biomedcentral.com).

Another much smaller study on 126 adult patients evaluated the quality of CPR provided by the emergency response team at a tertiary care hospital, focusing on chest compression fraction and its association with the return of spontaneous circulation during in-hospital cardiac arrest. In this case, they found the mean CCF was in line with the previous meta-analysis at 78%. In the study, patients who achieved ROSC had a higher average CCF (80%) compared to those who did not (75%). What’s more, higher CCF correlated to better outcomes. This study also noted that patients with initial shockable rhythms were more likely to get high chest compression fraction (81% of above) (Journals.lww.com).

I’ll add that the fact that those with initial shockable rhythms had lower CCF make sense, given the extra steps code blue teams must perform when faced with an initially unshockable rhythm.

Finally, I wanted to look at the range of CCF being performed in facilities. If the median is around 74-78% as the above studies found, how far do medical professional deviate from the mean?

A 2022 study had the answer I was looking for. They found a ± 7.52% from their mean of 72%, signifying that some patients received CCF as low as 64%. (Nih.gov)

However, the researchers also noted some interesting factors they found that lead to lower CCF:

• Longer resuscitation durations (more than 15 minutes)
• Increased number of team members during resuscitation.
• More personnel giving compressions (increased confusion and lack of synchrony).

It’s important to consider these factors as you work to improve the CCF for yourself or your team. 

How Can You Achieve a High Chest Compression Fraction?

1. Focus on Minimizing Interruptions

To ensure chest compressions are continuous, practice giving them with minimal pauses. Other ACLS activities are vital (assessments, setting up equipment, etc.). However, you can practice performing these critical tasks as quickly and accurately as possible as an individual and a team.

Additionally, you can minimize interruption by avoiding breaks during team member changes or non-clinical tasks by planning ahead, practicing with your team, and ensuring everyone is working from the same playbook. That “playbook” should be evidence-based decision-making that you memorize and know by heart, thereby reducing the time needed to decide what to do next. A great way to practice making these split-second decisions by completing ACLS Megacodes.

2. Use of Real-Time Feedback Devices

When available, employ real-time feedback tools that can monitor compression rate, depth, and frequency. Practicing with real-time feedback can help improve your compressions when you don’t have the luxury of these tools. Your create muscle memory. You can also use these devices to assess your performance after the emergency has passed so you can adjust your technique to meet that 80% of higher standard.

3. Limit Pulse Checks and Rhythm Assessments

Assessments are vital to understanding the situation. However, once you commit to CPR, try to keep these to a minimum. ACLS algorithms state you should perform CPR for a full two minutes before pausing to assess or adjust your strategy.

4. Optimize Team Dynamics

If you’re in a lead position, ensure your team understands roles and responsibilities to avoid confusion. If you’re not in charge, maintain open and honest communication about the importance of high CCF and share research related to its importance.

Remember: one of the factors that led to low CCF was too many people on the team. Fewer people with designated roles appear to be the optimal code-blue team structure. This may include well-timed multi-tasking, where one team member performs several roles that don’t ave to be performed at the same time. Those not part of this slim and elite code blue team must stay out of the way and not attempt to help unless a core member cannot perform their duty.

Every team member should Get ACLS certified and maintain their certification. You can complete AMC’s ACLS certification course 100% online in your spare time. You’ll gain access to ILCOR-aligned, evidence-based algorithms, study guides, videos, megacodes, practice tests, an app, and other tools to set you up for success. Find out about group discounts. You can even earn AMA 1 and other types of continuing medical education credits.

5. Practice and Simulation

Build regular in-person CPR team drills around various common—and less common— scenarios. Get your code blue team working as a unit. Knowing what to do in what order and when will become second nature, ensuring smooth hand-offs between team members and reducing disagreements at critical moments during emergencies.

Online simulations are also incredibly useful here. And I’m not necessarily speaking about virtual reality (VR) or augmented reality (AR), although those are nice, too, when available.  Even written megacodes that walk you through evidence-based decision-making challenges develop faster processing skills and mental muscle memory for what to do next, reducing downtime. 

Teams that regularly practice communication protocols, like those recommended in Advanced Cardiovascular Life Support (ACLS), reduce unnecessary pauses during resuscitation. When team members know what to expect and can predict the next steps, it cuts down on time spent figuring out who should do what, directly impacting CCF. A well-rehearsed team minimizes delays in switching compressors or during defibrillation, keeping compression interruptions brief.

6. Focus on Enhancing Team Communication

Clear, concise instructions ensure that every team member knows their role and can act without hesitation. In high-pressure scenarios, a lack of communication can result in confusion and delayed actions, lowering chest compression fraction (CCF) and negatively affecting outcomes.

7. Alternate Techniques May Increase Chest Compression Fraction

These are still investigational or less common, but I would like to bring them to your attention because they are currently showing promise. Researchers are using hands-on defibrillation and artifact filtering technology to reduce pauses.

Hands-on defibrillation (HOD) is the act of performing chest compressions during defibrillation to minimize CPR pauses. Of course, it involves using a barrier to prevent shocking the code blue team and those barriers, such as specialized, multi-layered gloves, are currently being tested.

A 2020 review of 35 studies on this topic found that HOD appears generally safe, but single-layer protective gloves currently on the market do not protect rescuers. They also found that HOD improved both CCF and CPP (coronary perfusion pressure). (ScienceDirect.com)

Similarly, you have artifact filtering technology. Artifacts refer to unwanted distortions in electroencephalogram (EEG) and electrocardiogram (ECG) data (ScienceDirect.com).

Most relevant to your practice, these distortions on the ECG are caused by various factors, such as your patient’s involuntary muscle movement or even your chest compressions. These can lead to false alarms and misdiagnoses of heart activity. In turn, you might make a treatment decision based on inaccurate information.

For this reason, you may have to stop compressions periodically to get an accurate reading. However, filtering technology is in the works that can ignore these distortions in the readout to more accurately present your patient’s EEG results. 

For example, adaptive motion artifact removal uses optical sensors integrated into the electrodes to track motion artifacts (e.g., compressions) and automatically remove them from the readout. These sensors can measure “skin strain” caused by patient or rescuer movements (AAMI.org).

What’s more, artificial intelligence ECG technology is currently being used on a limited but increasing basis. In this case, AI could use machine learning to identify the subtle difference between artifacts and real electro-cardio activity to scrub the artifacts out in real time (NIH.gov).

I look forward to seeing these technologies gain more everyday use, as I can see great potential here for emergency response team leaders exploring how you can increase chest compression fraction during a code.

Why ACLS Certifications Are So Critical to Increasing CCF

Ongoing training in ACLS (Advanced Cardiovascular Life Support) and PALS (Pediatric Advanced Life Support) is crucial for improving chest compression fraction (CCF). Regular practice following the same algorithms ensures that health care professionals like you and your team maintain proficiency in skills, enabling everyone to perform high-quality CPR without delays or interruptions. You can renew your PALS & ACLS certifications through AMC’s 100% online, evidence-based medical training courses.

Advanced Medical Certification is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), which allows them to provide continuing medical education credits to put toward renewing your license. Start learning ACLS for free here.

Frequently Asked Questions About CCF

How do you measure chest compression fraction?

Chest compression fraction (CCF) is measured by calculating the percentage of time spent performing chest compressions during a cardiac arrest event. It’s typically monitored using devices that track compressions in real time or by reviewing post-event data from defibrillators or CPR feedback systems

What is a good chest compression fraction?

A good chest compression fraction is 80% or higher. This means compressions are performed at least 80% of the time during the resuscitation effort, ensuring continuous blood flow to vital organs