Studies show that bystander-administered CPR can improve outcomes for out-of-hospital cardiac arrest but only 32% of cardiac arrest victims get CPR from a bystander. What can the industry do to improve bystander knowledge/training and improve access to AEDs where needed?

By Yoona Ha

Every year, millions of Americans are trained on how to perform CPR, yet only a few actively step in when they see someone experience sudden cardiac arrest. According to the American Heart Association, only 32% of out-of-hospital cardiac arrest (OHCA) victims receive CPR from bystanders.[1] Another study, published in Circulation, revealed that among 10,000 OHCA cases, only 22.1% of those who received bystander CPR survived.[2]

Turns out, these numbers contextualize the findings of other studies, which suggest that some communities have even lower rates of bystander CPR. For instance, one 2019 study [3] concluded that neighborhoods, where at least 50% of the residents were Hispanic were 39% less likely to receive bystander CPR than those who were living in neighborhoods that were less than 25% Hispanic.

Despite decades of education and widespread course offerings, bystander CPR rates have remained low. But with more information on which communities face the highest disparities in bystander CPR participation, providers can target the communities that need CPR education and resources the most.

Understanding the Barriers to Bystander CPR Intervention

For your average bystander, seeing someone collapse onto the floor from sudden cardiac arrest can be a harrowing experience. One of the first questions, EMS educators like James Boomhower asks his students in CPR training is what they would do if they were in the shoes of the bystander.

The answers may vary, he said. After training thousands of students on how to do CPR for 15 years, Boomhower, who is also an educator at the American Heart Association, is used to dispelling myths and misconceptions about CPR. Here are some examples that he shared with RT Magazine.

When Panic Leads to Inaction

Can panic lead to inaction? Unfortunately, the answer is very much so.

“The more bystanders you see around someone with sudden cardiac arrest, the more you can assume the mentality that ‘someone else is going to help,’” said Boomhower, who works as a critical care transport specialist at Boston MedFlight. “As a professional rescuer, you can almost feel the desperation from the crowd to take a load off of saving someone’s life.”

A 2017 study on bystanders’ perspectives on what facilitates CPR revealed that prior experiences with CPR training and using AEDs are leading factors for participation.[4]

“Communities can push for opportunities for CPR training by asking schools to incorporate them into high school curriculums, but education helps people understand how critical CPR is for a patient’s chain of survival,” he said.

CPR Misinformation Can Be Deadly

“Accidentally causing harm to someone during CPR is the No.1 concern that I hear as an instructor, it’s a fair concern but this is truly uncommon,” said Boomhower. “In fact, anything you can do is more helpful than nothing.”

And then there’s the fear of potential litigation. Can the victim sue for not doing CPR correctly? The good news is that all states have Good Samaritan laws that protect those who render aid during a time of crisis.

For now, Boomhower advises his students to consider stepping in first, rather than wait. In fact, a 2019 review of lawsuits that date back to 1989 found that “the likelihood of facing litigation is significantly higher in cases where bystander CPR was delayed or not provided.”[5]

“It’s up to the individual to research the Good Samaritan laws of their own states, but don’t let that keep you from saving someone’s life, even if you don’t have training,” Boomhower said.

Another concern that gets raised often in CPR classrooms is about the risk of possible infection by performing CPR.

Some may worry that mouth-to-mouth ventilation could transmit infections like HIV or other bloodborne viruses. Of course, there’s always that risk, but mouth-to-mouth resuscitation is no longer a part of the American Heart Association’s guidelines for CPR.

In fact, it recommends hands-only CPR which calls for bystanders to push the victim’s chest hard and fast at the rate of 100-120 compressions per minute and keep going until EMS personnel arrive.

One Nonprofit’s Answer: No-cost Online CPR Training

Audrey L. Blewer, PhD, MPH, assistant professor in the Department of Family Medicine and Community Health at Duke University School of Medicine, authored another study that showed that older age, lesser education, and lower income were factors associated with reduced likelihood of CPR training.[6]

“Location, cost of certification and time commitment can definitely be big barriers for training,” said Mackenzie Thompson, marketing director of, a nonprofit that specializes in online CPR training certification. “That’s why we offer free certifications for people who don’t have access to traditional CPR training resources and paid certifications for medical professionals.”

Thompson said she hopes that by offering no-cost certification opportunities that are available anywhere and anytime on-demand available for free online, these efforts will empower 10 million people to undergo CPR training by 2025.  

In 2018, the nonprofit added Spanish translated resources to its arsenal of no-cost CPR training and hopes to add more languages to its online program.

“There’s a need for more multi-language CPR education to reflect the growing diversity of our communities,” she added. “This is just one approach to addressing this multi-faceted problem.”

Can AEDs Help Improve Bystander CPR Rates? What to Consider

According to a 2018 study,[7] survival from cardiac arrest doubled when bystanders stepped in to use publicly available AEDs. The challenge as Boomhower sees it, is finding out where they are sometimes.

As a first responder, Boomhower doesn’t just instruct others on dispatch-aided CPR, but he also races against the clock to get the caller near an AED machine.

“Making it as easy as possible for the rescuer to have the courage and peace of mind to help as a bystander before EMS arrives is key,” said Karen Jasmin, Zoll Medical’s senior director of AED marketing. “High-quality CPR is the key to the chain of survival. Having an AED with real-time CPR feedback on rate and depth of compressions will help provide a rescuer the knowledge they are doing it correctly.”

The Zoll AED Plus is an example of an AED that has visual cues and clear audio that prompts instructions and feedback for bystanders. Not pressing fast or hard enough? The AED Plus lets bystanders know as they’re following those instructions in real-time.

‘There are many usability studies that we lean on to get firsthand feedback within the design phase of our products to better understand what will make AEDs easier to use for panicked bystanders,” she added. 

AEDs should be designed in a way that helps even an untrained bystander become a lifesaver. Jasmin added that the visual cues on Zoll Medical’s AEDs were included to help provide guidance for multi-lingual users in mind. As of today, Zoll Medical’s Cardiac Science AEDs have built-in multilingual functions that users can easily choose from.

A good first step to take meaningful progress in increasing bystander CPR participation involves understanding which communities need CPR training and resources the most and what the existing barriers are.

By taking a closer look at the relationships among community characteristics, race and ethnicity, language barriers and access to AEDs can help the design and evaluation of programs intended to improve CPR awareness.

“I hope to see not only more research to be done on bystander CPR, but also additional advocacy, public policies and training that address these disparities by highlighting just how important CPR is,” said Blewer. “It doubles a victim’s chance of survival from sudden cardiac arrest and knowing this can help us improve outcomes and save more lives.”


Yoona Ha is a contributing writer to RT. For more information contact [email protected].


  1. American Heart Association. (ND.) CPR Statistics.
  2. Brady W, et al. “Lay Responder Care for an Adult with Out-of-Hospital Cardiac Arrest.” N Engl J Med 2019;381:2242-2251. / DOI: 10.1056/NEJMra1802529
  3. Blewer A. “Variation in Bystander Cardiopulmonary Resuscitation Delivery and Subsequent Survival From Out-of-Hospital Cardiac Arrest Based on Neighborhood-Level Ethnic Characteristics.” Circulation. 2020;141:34–41.
  4. Hansen, Carolina Malta, et al. “Lay Bystanders Perspectives on What Facilitates Cardiopulmonary Resuscitation and Use of Automated External Defibrillators in Real Cardiac Arrests.” Journal of the American Heart Association, 2017;6:3. doi:10.1161/jaha.116.004572.
  5. Murphy T, et al. “Abstract 241: Legal Risk Of Bystander Cardiopulmonary Resuscitation.” Circulation. 2019;140:A241.
  6. Blewer A, et al. “Cardiopulmonary Resuscitation Training Disparities In The United States”. Journal of the American Heart Association. 2017:6;5. doi:10.1161/jaha.117.006124.
  7. Pollack R, et al. “Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests.” Circulation. 2018;137:2104–2113