When the Resuscitation Team Reports Barriers, CPR Quality Suffers: The Evidence

📌 Key Points

• In 42.5% of in-hospital cardiac arrests, resuscitation team members report at least one barrier that compromised the quality of their response.
• The presence of barriers is associated with a 45% reduction in the odds of achieving a guideline-compliant chest compression fraction (CCF) (≥80%).
• Among the three barrier categories studied (optimal resuscitation, teamwork, communication), it is communication barriers that have the most pronounced impact on measured CPR quality.
• These findings come from objective defibrillator data matched to post-event surveys — a unique methodology in the in-hospital cardiac arrest literature.
• These are modifiable targets: improving team communication could directly improve CPR quality.

Introduction

CPR (cardiopulmonary resuscitation) quality is known to directly influence survival after an in-hospital cardiac arrest (IHCA). Each additional 5 seconds of pause in chest compressions is associated with lower rates of return of spontaneous circulation (ROSC). A high chest compression fraction (CCF) and compressions at the correct rate are predictors of better clinical outcomes.

But in clinical reality, resuscitation teams rarely operate under optimal conditions. Communication problems, role confusion, faulty equipment, unclear leadership, inadequate staffing — these are situations that any clinician who has participated in a code blue will recognize immediately.

The key question is: do these team-perceived barriers translate into a measurable deterioration in CPR quality?

This is exactly what Lauridsen and colleagues set out to quantify in this Danish study published in Resuscitation in 2026. By matching post-event survey data — completed immediately after each IHCA — with objective transthoracic impedance data extracted from defibrillators, this team produced the first direct evidence of the association between team-reported barriers and delivered CPR quality.

Study Summary

Field	Details
Reference	Agervig F, Gedde AR, Østergård AV, Nettinger M, Müller SD, Nielsen RP, Nadkarni VM, Wittig J, Løfgren B, Lauridsen KG. Resuscitation. 2026;221:111030
Type	Multicenter prospective mixed-methods cohort
Population	313 IHCAs with matched data (survey + defibrillator), 4 regional hospitals in Denmark
Period	May 2017 to April 2022 (5 years)
Primary Outcome	Duration of the longest chest compression pause
Secondary Outcomes	CCF ≥80%, guideline-compliant compression rate (100-120/min)
Senior Author	Kasper G. Lauridsen — Randers Regional Hospital & Aarhus University, Denmark
Notable Author	Vinay M. Nadkarni — Children’s Hospital of Philadelphia, University of Pennsylvania
DOI	10.1016/j.resuscitation.2026.111030

Methodology

Study Design: Prospective mixed-methods multicenter cohort conducted in 4 regional hospitals in the Central Denmark Region. STROBE design (Strengthening the Reporting of Observational Studies in Epidemiology). Approved by the regional ethics committee (no. 1-16-02-113-16) and exempt from individual consent.

Barrier Collection: An online “just-in-time” debriefing tool was sent to all cardiac arrest team members after each resuscitation attempt. The survey included three Likert-type questions (1-5) covering: (1) optimal resuscitation (technical aspects — equipment, algorithm, medications, rhythm checks), (2) teamwork (role assignment, leadership, crowd control, collaboration with unit staff), and (3) communication (closed-loop communication, clear verbalizations). An open-ended question allowed free comments, analyzed qualitatively by thematic coding.

Barrier Definition: An event was classified as “with barrier” if at least one team member reported a low Likert score (1-3 out of 5) AND/OR a free comment with negative sentiment. Two authors independently analyzed each comment, with group discussion for disagreements.

CPR Quality Data: Transthoracic impedance data extracted from defibrillators (Lifepak 20, Stryker/Physio-Control) via CODE-STAT software. Defibrillators had no real-time feedback function. Measurements: longest pause duration, CCF, compression rate.

Matching: Survey responses were matched to defibrillator files using hospital codes, timestamps, and event identifiers. Of 3,726 survey responses, 873 (23.4%) could be matched with defibrillator data, corresponding to 313 IHCAs.

Statistical Analysis: Directed acyclic graphs (DAGs) for confounder identification. Generalized linear regression for pause duration (adjusted for site, defibrillation, rhythm). Mixed-effects logistic regression for CCF and rate (adjusted for site clustering).

Results

Barrier Prevalence

Of the 313 IHCA events analyzed, 133 (42.5%) had reported barriers. In the barrier group, the median number of barriers reported per event was 3 (interquartile range: 2-5). This means that nearly one in two IHCAs is perceived as suboptimal by the resuscitation team members.

CPR Quality: With and Without Barriers

Metric	Total (n=313)	Without barriers (n=180)	With barriers (n=133)
Longest pause, median [IQR], sec	16 [10;29]	15.5 [9;26]	19 [12;34]
CCF, median [IQR], %	82 [78;86]	83 [78;87]	81 [76;85]
Compliant rate (100-120/min), n (%)	178 (56.9%)	101 (56.1%)	77 (57.9%)

Primary Outcome: Longest Pause

The presence of reported barriers was associated with a 3.2-second increase in the longest compression pause (95% CI: -1.9 to 8.4; p = 0.22). This result is not statistically significant. The confidence interval is wide and includes zero, meaning the study cannot conclude an association for the primary outcome as defined.

Key Secondary Outcome: CCF ≥ 80%

This is where the study delivers its most striking finding. The presence of reported barriers was associated with an OR of 0.55 (95% CI: 0.35-0.89; p = 0.01) for achieving a CCF ≥ 80%. In other words, when barriers were reported, the odds of achieving an AHA-compliant CCF were reduced by 45%.

Communication: The Primary Driver

Analysis by barrier category reveals a finding particularly relevant to practice. Among the three predefined categories — optimal resuscitation, teamwork, and communication — only communication barriers were significantly associated with a non-guideline-compliant compression rate (OR = 0.53; 95% CI: 0.29-0.95).

Teamwork and optimal resuscitation barriers did not reach statistical significance for the individually measured metrics.

Key Findings

1. First study linking perceived barriers to measured quality. This is the major original contribution. Before this study, barriers were known to exist and were suspected to affect quality — but no one had demonstrated this with objective defibrillator data.
2. 42.5% of IHCAs have reported barriers. This is an alarming figure. Nearly one in two IHCAs is perceived as suboptimal by the team itself. If we consider that reporting likely underestimates the reality, the problem is potentially even more widespread.
3. Communication is the most determining factor. It is not equipment, it is not algorithms — it is communication among team members that has the most measurable impact on CPR quality. This finding has direct implications for training and quality improvement.
4. The primary outcome is negative. It must be stated clearly: the study found no significant association between barriers and the duration of the longest pause. It is the secondary outcome (CCF) that carries the positive result. This methodological distinction is important for interpretation.

Strengths

1. Innovative and robust methodology. Matching subjective data (post-event surveys) with objective data (defibrillator waveforms) is a unique approach in the IHCA literature. This goes beyond purely qualitative studies on barriers.
2. 5-year multicenter prospective design. The observation period and inclusion of 4 regional hospitals increase external validity and reduce the risk of temporal selection bias.
3. Rigorous analytical framework. The use of directed acyclic graphs (DAGs) to identify confounders, mixed-effects models for site clustering, and the STROBE approach demonstrate high methodological rigor.
4. Leading authorship team. Kasper Lauridsen is a prolific researcher in the IHCA field with multiple publications on CPR quality in Denmark. Vinay Nadkarni (CHOP/University of Pennsylvania) is one of the world’s leading researchers in pediatric resuscitation and a co-author of ILCOR recommendations. Johannes Wittig and Bo Løfgren are members of the ERC 2025 guidelines writing group.
5. Published in Resuscitation. The leading journal in resuscitation, with an impact factor of 4.6 (2025), CiteScore of 12.2, Q1. Official journal of the European Resuscitation Council.

Limitations

1. Low matching rate — only 23.4% (possible selection bias). Of 3,726 survey responses, only 873 could be matched with defibrillator data, primarily because hospitals did not automatically transmit defibrillator data. The authors assume missing data are missing at random, but this is not demonstrated. If missing cases had a different barrier or quality profile, results could be biased.
2. Barrier dichotomization (measurement bias). Classifying an IHCA as “with barrier” as soon as a single team member reports a problem may be an oversimplification. A single negative comment in a team of 6 may not reflect the collective experience. The authors acknowledge this limitation.
3. Negative primary outcome. The study did not reach statistical significance for its primary outcome (longest pause). The positive result (CCF) comes from a secondary outcome, requiring cautious interpretation. The study may have been underpowered to detect a difference in pause duration.
4. No survival data (attrition bias in clinical reasoning). The study does not report the link between barriers and patient survival. CCF is known to be associated with survival, but the direct chain “barriers → worse CCF → worse survival” is not demonstrated here.
5. Unmeasured confounders. The authors had no data on team member experience, number of people present, time of day, or initial patient severity. These factors could confound the relationship between reported barriers and CPR quality.
6. Conflicts of interest. Several authors have ties to industry (Laerdal) and normative organizations (ERC, ILCOR, Resuscitation Plus). These conflicts are declared but merit noting, particularly for a study that could justify investments in training and feedback equipment.

Discussion

What the study shows. For the first time, objective defibrillator data confirm what clinicians suspected: when resuscitation team members report problems, CPR quality concretely suffers. CCF — an indicator directly linked to survival — is significantly lower when barriers are reported.

Why this matters. This result transforms resuscitation barriers from a topic of “anecdotal complaint” into a measurable and modifiable risk factor. We are no longer talking about provider comfort — we are talking about quality of care and, by extension, patient survival. For hospital managers questioning the investment in team training, this study provides an objective argument.

What may be misinterpreted. The study could be read as “barriers cause poor CPR.” That is not what it says. The association is clear, but causality is not demonstrated in an observational design. It is possible that intrinsically more difficult IHCAs (complex patients, chaotic situations) generate both more reported barriers AND lower CPR quality, without one directly causing the other.

What the study does not allow us to conclude. The study does not demonstrate that reducing barriers improves CPR quality or survival. It identifies an association, not a causal mechanism. Interventional studies — such as cluster randomized trials testing training programs targeting communication — would be needed to complete the picture.

Comparison with the literature. A recent qualitative study (International Journal of Emergency Medicine, 2025) identified 24 themes of barriers and facilitators in CPR teams, with closed-loop communication as the dominant theme. Lauridsen and colleagues published a prospective qualitative study in the same cohort in 2021, identifying barriers (Resuscitation 2021;164:70-8). The present study adds the quantitative dimension with defibrillator data. The AHA 2025 guidelines highlight that nearly half of resuscitation errors stem from teamwork and leadership problems.

Canadian Perspective. In Canada and Quebec, post-IHCA debriefing remains an uncommon practice. The majority of hospitals do not have a structured post-event data collection system comparable to the tool used in this study. Implementing a post-code blue survey — even a simple one — would be a first step to identifying local barriers and targeting interventions.

Link to SCORE. This study is one of the most directly relevant to SCORE of this entire analysis series. SCORE targets precisely the communication, coordination, and leadership barriers identified here as the most determining for CPR quality. Lauridsen’s data provide solid empirical justification for the program’s core components: pre-assigned roles, structured communication, systematic debriefing, and regular in situ simulation training. The figure of 42.5% of IHCAs with reported barriers is a powerful selling point for hospital decision-makers.

Authors’ Conclusion

“In this multicenter, prospective cohort study, the presence of any self-reported barriers during IHCA were associated with a lower CCF but not with a significantly different longest pause duration or guideline-compliant chest compression rates. Reported communication barriers were specifically associated with non-guideline-compliant compression rates and appeared as an important driver for the association with lower CCF, compared to optimal resuscitation barriers and teamwork barriers.”

Conclusion

This study is an important milestone for anyone working to improve the response to in-hospital cardiac arrests. For the first time, objective defibrillator data demonstrate that team problems reported by clinicians are not mere frustrations — they translate into measurably lower CPR quality.

The most actionable finding is the central role of communication. It is not equipment or algorithm problems that most degrade quality — it is the difficulty of communicating clearly during resuscitation. Closed-loop communication, clear team leader instructions, and structured verbal coordination are teachable, trainable, and measurable skills.

In light of this evidence, here is what I would do in practice today: first, I would implement a simple, quick post-event survey after every code blue — even a 3-question form like the one used in this study — to begin mapping local barriers. Second, I would prioritize training in structured communication during resuscitation simulations. Third, I would use the 42.5% figure — nearly one in two IHCAs with reported problems — as an argument in my presentations to hospital decision-makers. This is exactly what SCORE does: identify barriers, measure them, target them through training, and track them over time.

Clinical Bottom Line

Nearly one in two in-hospital cardiac arrests is perceived as suboptimal by the resuscitation team itself. These barriers — particularly communication problems — are associated with a 45% reduction in the odds of achieving a guideline-compliant chest compression fraction. These are modifiable targets. Investing in structured communication training, systematic post-event debriefing, and pre-assigned roles is an evidence-based strategy to improve CPR quality during code blues.