Multifactorial Determinants of Cardiopulmonary Resuscitation Quality in the Emergency Department: A Narrative Review

In-hospital cardiac arrest survival rates remain 20-30% despite guideline advances, with emergency department (ED) resuscitation uniquely challenged by crowding, staff turnover, and diagnostic uncertainty. While technical CPR benchmarks are well-defined, consistent ED performance varies widely, suggesting system, human, and environmental factors significantly influence outcomes. Successful CPR outcomes depend not only on the quality and technique of resuscitation being performed but also on various contributing factors that concurrently influence the overall effectiveness of CPR in the patient. This narrative review synthesizes multifactorial determinants of CPR quality specific to ED practice. PRISMA 2020-guided narrative synthesis across PubMed, Scopus, and Web of Science (January 2010-March 2026). Boolean search terms identified 1,247 records; two independent reviewers screened 1,189 titles/abstracts and assessed 189 full texts, excluding 159 (non-ED focus n = 102, pediatric/out-of-hospital n = 34, and non-English n = 23), yielding 52 studies categorized into five thematic domains. ED crowding independently reduces chest compression fraction (CCF) 11% and delays defibrillation 42 seconds (OR 1.4); leadership absence causes 2.1-fold longer shock delivery; procedural interruptions from intubation and point-of-care ultrasound (POCUS) average 12-19 seconds reducing CCF 8-17%; intraosseous access achieves 92% success vs. 59% IV failure; mechanical CPR devices improve CCF 92% vs. 78% manual but show no survival benefit; family presence adds 4.7-second pauses despite psychological benefit to 85% families. ED CPR quality reflects a complex interplay of system strain (CCF reductions 11-28%), human factors (leadership delays OR 2.1), technology integration challenges (POCUS pauses 12-19 seconds), procedural workflow, and patient complexity. Current quality improvement must extend beyond technical training to address these modifiable ED-specific barriers.