Why Are Bystander CPR Rates So Low?

Survival from out-of-hospital cardiac arrest in the United States is less than ten percent on average. One reason why cardiac arrest survival rates are so low is that few bystanders do CPR.

CPR Is Important
Early cardiopulmonary resuscitation (CPR) is a strong predictor of survival in sudden cardiac arrest. However, bystanders in the US only do CPR in 15 to 30 percent of out-of-hospital cardiac arrests.(1) In many communities the number is closer to 15 percent.

The odds of survival drop significantly after four to six minutes without CPR in witnessed arrests (and the victim’s heart rhythm is ventricular fibrillation).(2,3) This is a problem because EMS providers generally can’t get to a scene for six to eight minutes and it usually takes a few minutes for someone to recognize cardiac arrest and call to 911.

How can we greatly increase the number of bystanders who do CPR? What don’t people do CPR? The challenge is to train more people in CPR and to make sure that those who are trained do not hesitate to act.

Why People Don’t Do CPR
There are many reasons why people do not learn CPR. Those who do not take a course cite a lack of time or interest, complexity of the CPR procedure, inconvenience of attending a class, and physical limitations for some students. Often CPR classes are long and contain unrelated information.

In addition, students who take a class may fail to learn, remember or may lack confidence for fear of doing CPR incorrectly. Surveys have shown some would-be rescuers fear causing further harm or failing to do things properly. Lastly, fear of being sued is a factor (although this fear is unfounded because of protections offered by Good Samaritan laws in the majority of states).

How to Improve Bystander CPR Rates
A recent review of scientific research by Vaillancourt, Stiell and Wells looked at efforts to improve bystander CPR rates.(4) They authors suggested more people likely would complete a CPR course if they understood the impact CPR has on actually saving a life.

One important finding from recent studies is more people are willing to do CPR if an emergency dispatcher guides them over the telephone. Other strategies are to motivate more people to take a class with more media coverage and advertising to the public about the impact CPR can have. And, for those who will not take a course, educating them about compressions-only CPR.

To get more people to complete CPR training, the public should be immersed with messages about the dramatic effects of CPR and Good Samaritan laws. The message that anyone can do chest compression-only CPR needs to be broadly conveyed. Other suggestions to reach more people are mass-CPR events, training high school students, and distributing promotional videos.

Other findings are that students should spend more time practicing on manikins and CPR class content needs to be shorted and simplified. Also, people should have accessed to better self-instructional courses so they can take learn CPR outside of a formal class. Finally, to assure quality CPR is delivered by those who have been trained, standards for performance should be set high.

Irrespective of the teaching method, retention of CPR knowledge and skills is poor and can significantly decrease as early as six weeks after a CPR class. Thus periodic refreshers are important.

A victim's chances of survival fall dramatically after a few minutes without CPR. For a victim to have a good chance, a bystander must start CPR early. Thousands of lives could be saved every year by implementing some measures including: increasing dispatcher-assisted CPR efforts, motivating more people to take a class, getting untrained people to do compressions-only CPR, and improving CPR instruction.


1. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423-1431.

2. Abella B, Aufderheide T, Eigel B, et al. Reducing Barriers for Implementation of Bystander-Initiated CPR. Circulation. 2008;117:704-709.

3. Cummins RO, Eisenberg MS, Hallstrom AP, Litwin PE. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation (1985) American Journal of Emergency Medicine, 3 (2), pp. 114-119. 

4. Vaillancourt C, Stiell I, Wells G. Understanding and improving low bystander CPR rates: a systematic review of the literature. CJEM. 2008;10(1):51-65