Firm Surface for CPR: An updated Systematic Review (BLS-2510)

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Gavin Perkins co-authored included papers.

CoSTR Citation

Dewan M, Perkins G, Schachna E, Eastwood K, Smyth M, Olasveengen TM, Bray J -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Optimal surface for CPR: An Updated Systematic Review and Meta-analysis. Available from:

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process to produce the Consensus on Science with Treatment Recommendations (CoSTR) is an update of the 2020 systematic review conducted by the BLS Task Force with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Basic Life Support Task Force. These data were accounted for when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published.



Description (with recommended text)


For adults or children in cardiac arrest (out-of-hospital and in-hospital)


The performance of CPR using a hard surface (e.g. backboard, floor, or deflatable or specialist mattress)


The performance of CPR on a regular mattress or other soft surface


Survival with a favourable neurological outcome at hospital discharge/30-days, survival at hospital discharge/30-days, event survival, ROSC, CPR quality (e.g. (e.g., compression depth, compression rate, compression fraction)

Study Design

Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) will be eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract.

Systematic Reviews and guideline publications and large case series n>20 are eligible for inclusion. Randomized manikin simulation or cadaver studies will only be included if insufficient human studies are identified.


September 17th 2019 to September 16th 2023

PROSPERO CRD42017080475

Consensus on Science

This topic was prioritized for update by the BLS Task Force following a systematic review in 2020.1 Members of the Task Force reported variation in backboard use and concern for delays in CPR with the practice of moving a patient from the bed to the floor to improve the quality of CPR, thus it was considered timely to review the published evidence.

In addition to the 11 manikin simulation RCTs2-12 identified by Holt et al.1, we identified one observational study13 and 6 additional manikin RCTs14-19 published since 2019 addressing this PICOST. The identified science has been grouped by the surfaces examined: Backboard Versus Hospital Mattress, Floor Versus Hospital Mattress, Floor Versus Firm Home Mattress, and Other Surface Types.

Backboard versus Hospital Mattress

One small observational study13 and 7 manikin RCTs4,5,7-9,11,17 compared using a backboard to a hospital-grade mattress. In all studies, CPR was performed by hospital personnel, including one study that used orderlies5 and two studies that used medical students.4,11

No studies reported patient outcomes.

For the important outcome of compression depth, we identified low certainty evidence (downgraded for serious indirectness) from 1 small observational study13 and 7 manikin RCTs.4,5,7-9,11,17 The observational study of 26 in-hospital cardiac arrests (IHCAs), used an single accelerometer (CPR feedback device) placed on the chest, reported an increase in the mean proportion of compressions at guideline targets when a backboard was used (72.9% vs 48.7%, p=0.05). However, this study did not adjust for mattress compression, therefore the difference in compressions is unreliable. A meta-analysis of the 7 simulation RCTs using a manikin to measure depth, showed a 2.16 millimeter (95% CI 0.52 to 3.81) improvement in chest compression depth when a backboard was used on hospital foam mattresses 6cm to 14 cm thick.

For the important outcome of compression rate, we identified low certainty of evidence (downgraded for serious indirectness) from 5 manikin RCTs.4,5,7,11,17 Meta-analysis using a manikin to measure rate, show no difference in chest compression rate with the use of a backboard (mean difference -0.11, 95%CI: -3.8 to 3.59).

We did not identify any evidence to address the important outcomes of chest compression fraction or interruptions to CPR.

Floor versus Hospital Mattress

Two manikin RCTs compared the floor to a hospital-grade mattress, in both studies CPR was performed by critical care staff.3,6

No studies reported patient outcomes.

For the important outcome of compression depth, we identified low certainty evidence (downgraded for serious indirectness) for two manikin RCTs.3,6 Meta-analysis showed no difference (5.36 millimeter, 95% CI -1.59 to 12.32) in chest compression depth when CPR was performed on a manikin placed on the floor compared to a hospital mattress.

For the important outcome of compression rate, we identified low certainty evidence (downgraded for serious indirectness) from two manikin RCTs.3,6 Both studies reported no difference in mean compression rates between surfaces.

For the important outcome of no flow time, we identified very low certainty of evidence (downgraded for serious indirectness and imprecision) from 1 manikin RCT.6 No difference in mean no flow time was reported, but this was not defined.

Floor versus Firm Home Mattress

Two studies compared the floor to a firm home mattress, CPR was performed by CPR trained hospital personnel12 or lay-persons.19

No studies reported patient outcomes.

For the important outcome of compression depth we identified low certainty evidence (downgraded for serious indirectness) from 2 manikin RCTS.12,19 Meta-analysis of these studies showed no difference (mean difference 2.11 millimeters, 95% CI -3.23 to 7.45) in chest compression depth when CPR was performed on a manikin placed on the floor compared to a firm home mattress. One study also reported data for medium and soft mattress, with no difference reported between surfaces.12

For the important outcome of compression rate we identified low certainty evidence (downgraded for serious indirectness) from 2 manikin RCTS.12,19 Both studies reported no difference in rate when CPR was performed on a firm mattress; one study reported lower median CPR rates when CPR was performed on a soft home mattress and this rate was below guideline recommendations (98.5/min, IQR 91-107).12

One manikin RCT reported no difference in chest recoil between the floor or varying mattress surfaces.12

One manikin RCT reported significantly less self-reported fatigue and more comfort when CPR was performed on the floor compared to a mattress.12

Other Surface Types

Two manikin RCTs examined the performance of CPR on other surfaces, including sports matting15 and dental chairs.16

No studies reported patient outcomes.

The first study compared CPR quality and rescuer fatigue on three surfaces: the floor, low compliance safety sports matting with and without backboard, high compliance (i.e., softer) safety sports matting with and without a backboard.15 For CPR quality metrics, high compliance matting with and without a backboard had a significantly lower compression rate and compression depth compared to floor or low compliance matting with and without backboard. Perceived exertion was highest on high compliance matting, with no difference found in rescuer’s heart rate. This study had a high risk of bias, as five female participants were excluded for failure to reach a predetermined depth on the solid floor.

The second study evaluated chest compression rate and depth in two different dental chairs versus the floor.16 The percentage of chest compressions ³5 cm was significantly lower in both dental chairs compared to the floor.

Treatment Recommendations

We suggest performing chest compressions on a firm surface when this is practical and does not significantly delay the commencement of chest compressions (weak recommendation, very low certainty evidence).

We suggest against moving a patient from a firm mattress to the floor to improve chest compression depth (weak recommendation, very low certainty of evidence).

For healthcare systems that have already incorporated backboards into routine use during resuscitations, the evidence was considered insufficient to suggest against their continued use (weak recommendation, very low certainty of evidence). For healthcare systems that have not introduced backboards, the limited improvement in compression depth and uncertainty about harms seemed insufficient to justify the costs of purchasing backboards and training staff in their use (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

In making these recommendations, the BLS Task Force considered the importance of high-quality chest compressions and minimizing delays to the initiation of CPR to improve outcomes from in-hospital and out-of-hospital cardiac arrest.

When performing chest compressions on a mattress, the compression force is dissipated through both chest compression and compression of the surface beneath the patient. Prior studies using mannequins indicate that mattress compression can be as high as 57% of total compression depth, with greater compression seen in softer mattresses.20-22 This can lead to reduced spinal-sternal displacement and a reduction in effective chest compression depth.

It is known that effective compression depths can be achieved on soft surfaces if the CPR provider increases overall compression depth to compensate for mattress compression.23-26 CPR feedback devices, which account for mattress compression (e.g. the use of dual and not single accelerometers or increasing compression depth targets) can help CPR providers to ensure adequate compression depth when CPR is performed on a mattress.4,26-28

Within the limitations of mannequin studies, the available evidence indicates the use of a backboard on a hospital mattress only results in a marginal depth benefit and one that is unlikely to be clinically significant.

The Task Force also considered:

  • The lack of clinical studies reporting on the critical outcomes of favorable neurological outcome, survival, ROSC and delays to commencement of CPR.
  • The only human data was measured using a single accelerometer (feedback device) placed on the chest and did not adjust for mattress compression.
  • The weak recommendations are based on extrapolation from mannequin studies, where CPR was mostly performed by a trained healthcare professional. Only one study19 examined CPR performed by lay rescuers.
  • The hospital beds involved in the studies typically had a rigid base and ranged in thickness between 6 to 14cm. The Task Force noted that although this configuration is common in many developed country hospitals, this may not be applicable to all hospitals or the out-of-hospital setting.
  • The addition of two studies simulating out-of-hospital settings (where beds may be softer) and one where the CPR provider may be a single untrained rescuer, led to the Task Force to broaden the recommendations to include in-hospital and out-of-hospital cardiac arrest.
  • In considering whether to transfer a patient to the floor when performing chest compressions to improve compression depth, the Task Force considered the risks of harm (e.g. interruption in CPR, risk of losing vascular access if IV lines and more confined space) to the patient and resuscitation team outweighed any small improvement in chest compression depth. In addition, studies on bystander CPR report significant loss of time due to difficulties in moving the patient to the floor29 or that CPR is not performed because the patient could not be moved.29,30 Emergency Medical Services are likely to move patients in confined spaces to perform resuscitation.
  • The Task Force felt the indirect evidence on backboards was not sufficient to have backboards removed where they are currently used. Where backboards are deployed, users should be aware that mattress stiffness, backboard size and orientation influence their effectiveness.31-34

Knowledge Gaps

Current knowledge gaps include but are not limited to:

  • Human studies reporting clinical outcomes.
  • Studies examining the logistical aspects of backboard deployment or moving a patient from a bed to the floor.
  • Studies in both high and low-resource settings where hospital bed or pre-hospital stretcher configurations may vary.

EtD: BLS 2510 Optimal surface for CPR 2024 ETD


1. Holt J, Ward A, Mohamed TY, Chukowry P, Grolmusova N, Couper K, Morley P, Perkins GD. The optimal surface for delivery of CPR: A systematic review and meta-analysis. Resuscitation. 2020;155:159-164. doi: 10.1016/j.resuscitation.2020.07.020

2. Tweed M, Tweed C, Perkins GD. The effect of differing support surfaces on the efficacy of chest compressions using a resuscitation manikin model. Resuscitation. 2001;51:179-183. doi: 10.1016/s0300-9572(01)00404-x

3. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mattresses affect the quality of cardiopulmonary resuscitation? Intensive Care Med. 2003;29:2330-2335. doi: 10.1007/s00134-003-2014-6

4. Perkins GD, Smith CM, Augre C, Allan M, Rogers H, Stephenson B, Thickett DR. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med. 2006;32:1632-1635. doi: 10.1007/s00134-006-0273-8

5. Andersen LO, Isbye DL, Rasmussen LS. Increasing compression depth during manikin CPR using a simple backboard. Acta Anaesthesiol Scand. 2007;51:747-750. doi: 10.1111/j.1399-6576.2007.01304.x

6. Jantti H, Silfvast T, Turpeinen A, Kiviniemi V, Uusaro A. Quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed. Acta Anaesthesiol Scand. 2009;53:1131-1137. doi: 10.1111/j.1399-6576.2009.01966.x

7. Sato H, Komasawa N, Ueki R, Yamamoto N, Fujii A, Nishi S, Kaminoh Y. Backboard insertion in the operating table increases chest compression depth: a manikin study. J Anesth. 2011;25:770-772. doi: 10.1007/s00540-011-1196-2

8. Oh J, Chee Y, Song Y, Lim T, Kang H, Cho Y. A novel method to decrease mattress compression during CPR using a mattress compression cover and a vacuum pump. Resuscitation. 2013;84:987-991. doi: 10.1016/j.resuscitation.2012.12.027

9. Fischer EJ, Mayrand K, Ten Eyck RP. Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study. Am J Emerg Med. 2016;34:274-277. doi: 10.1016/j.ajem.2015.10.035

10. Putzer G, Fiala A, Braun P, Neururer S, Biechl K, Keilig B, Ploner W, Fop E, Paal P. Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study. J Emerg Med. 2016;50:594-600 e591. doi: 10.1016/j.jemermed.2015.10.002

11. Sanri E, Karacabey S. The Impact of Backboard Placement on Chest Compression Quality: A Mannequin Study. Prehosp Disaster Med. 2019;34:182-187. doi: 10.1017/S1049023X19000153

12. Ahn HJ, Cho Y, You YH, Min JH, Jeong WJ, Ryu S, Lee JW, Cho SU, Oh SK, Park JS, et al. Effect of using a home-bed mattress on bystander chest compression during out-of-hospital cardiac arrest. Hong Kong Journal of Emergency Medicine. 2021;28:37-42. doi: 10.1177/1024907919856485

13. Picard C, Drew R, Norris CM, O'Dochartaigh D, Burnett C, Keddie C, Douma MJ. Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data. J Emerg Nurs. 2022;48:224-232 e228. doi: 10.1016/j.jen.2021.11.005

14. Hasegawa T, Okane R, Ichikawa Y, Inukai S, Saito S. Effect of chest compression with kneeling on the bed in clinical situations. Jpn J Nurs Sci. 2020;17:e12314. doi: 10.1111/jjns.12314

15. Kingston T, Tiller NB, Partington E, Ahmed M, Jones G, Johnson MI, Callender NA. Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion. PLoS One. 2021;16:e0254800. doi: 10.1371/journal.pone.0254800

16. Shimizu Y, Sadamori T, Saeki N, Mukai A, Doi M, Oue K, Yoshida M, Irifune M. Efficacy of Chest Compressions Performed on Patients in Dental Chairs Versus on the Floor. Anesth Prog. 2021;68:85-89. doi: 10.2344/anpr-68-01-07

17. Cuvelier Z, Houthoofdt R, Serraes B, Haentjens C, Blot S, Mpotos N. Effect of a backboard on chest compression quality during in-hospital adult cardiopulmonary resuscitation: A randomised, single-blind, controlled trial using a manikin model. Intensive Crit Care Nurs. 2022;69:103164. doi: 10.1016/j.iccn.2021.103164

18. Torsy T, Deswarte W, Karlberg Traav M, Beeckman D. Effect of a dynamic mattress on chest compression quality during cardiopulmonary resuscitation. Nurs Crit Care. 2022;27:275-281. doi: 10.1111/nicc.12631

19. Missel AL, Donnelly JP, Tsutsui J, Wilson N, Friedman C, Rooney DM, Neumar RW, Cooke JM. Effectiveness of Lay Bystander Hands-Only Cardiopulmonary Resuscitation on a Mattress versus the Floor: A Randomized Cross-Over Trial. Ann Emerg Med. 2023;81:691-698. doi: 10.1016/j.annemergmed.2023.01.012

20. Lin Y, Wan B, Belanger C, Hecker K, Gilfoyle E, Davidson J, Cheng A. Reducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study. Adv Simul (Lond). 2017;2:22. doi: 10.1186/s41077-017-0057-y

21. Noordergraaf GJ, Paulussen IW, Venema A, van Berkom PF, Woerlee PH, Scheffer GJ, Noordergraaf A. The impact of compliant surfaces on in-hospital chest compressions: effects of common mattresses and a backboard. Resuscitation. 2009;80:546-552. doi: 10.1016/j.resuscitation.2009.03.023

22. Song Y, Oh J, Lim T, Chee Y. A new method to increase the quality of cardiopulmonary resuscitation in hospital. Annu Int Conf IEEE Eng Med Biol Soc. 2013;2013:469-472. doi: 10.1109/EMBC.2013.6609538

23. Beesems SG, Koster RW. Accurate feedback of chest compression depth on a manikin on a soft surface with correction for total body displacement. Resuscitation. 2014;85:1439-1443. doi: 10.1016/j.resuscitation.2014.08.005

24. Nishisaki A, Maltese MR, Niles DE, Sutton RM, Urbano J, Berg RA, Nadkarni VM. Backboards are important when chest compressions are provided on a soft mattress. Resuscitation. 2012;83:1013-1020. doi: 10.1016/j.resuscitation.2012.01.016

25. Lee S, Oh J, Kang H, Lim T, Kim W, Chee Y, Song Y, Ahn C, Cho JH. Proper target depth of an accelerometer-based feedback device during CPR performed on a hospital bed: a randomized simulation study. Am J Emerg Med. 2015;33:1425-1429. doi: 10.1016/j.ajem.2015.07.010

26. Ruiz de Gauna S, Gonzalez-Otero DM, Ruiz J, Gutierrez JJ, Russell JK. A Feasibility Study for Measuring Accurate Chest Compression Depth and Rate on Soft Surfaces Using Two Accelerometers and Spectral Analysis. Biomed Res Int. 2016;2016:6596040. doi: 10.1155/2016/6596040

27. Hellevuo H, Sainio M, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. The quality of manual chest compressions during transport--effect of the mattress assessed by dual accelerometers. Acta Anaesthesiol Scand. 2014;58:323-328. doi: 10.1111/aas.12245

28. Oh J, Song Y, Kang B, Kang H, Lim T, Suh Y, Chee Y. The use of dual accelerometers improves measurement of chest compression depth. Resuscitation. 2012;83:500-504. doi: 10.1016/j.resuscitation.2011.09.028

29. Dami F, Heymann E, Pasquier M, Fuchs V, Carron PN, Hugli O. Time to identify cardiac arrest and provide dispatch-assisted cardio-pulmonary resuscitation in a criteria-based dispatch system. Resuscitation. 2015;97:27-33. doi: 10.1016/j.resuscitation.2015.09.390

30. Case R, Cartledge S, Siedenburg J, Smith K, Straney L, Barger B, Finn J, Bray JE. Identifying barriers to the provision of bystander cardiopulmonary resuscitation (CPR) in high-risk regions: A qualitative review of emergency calls. Resuscitation. 2018;129:43-47. doi: 10.1016/j.resuscitation.2018.06.001

31. Cheng A, Belanger C, Wan B, Davidson J, Lin Y. Effect of Emergency Department Mattress Compressibility on Chest Compression Depth Using a Standardized Cardiopulmonary Resuscitation Board, a Slider Transfer Board, and a Flat Spine Board: A Simulation-Based Study. Simul Healthc. 2017;12:364-369. doi: 10.1097/SIH.0000000000000245

32. Cloete G, Dellimore KH, Scheffer C. Comparison of experimental chest compression data to a theoretical model for the mechanics of constant peak displacement cardiopulmonary resuscitation. Acad Emerg Med. 2011;18:1167-1176. doi: 10.1111/j.1553-2712.2011.01213.x

33. Cloete G, Dellimore KH, Scheffer C, Smuts MS, Wallis LA. The impact of backboard size and orientation on sternum-to-spine compression depth and compression stiffness in a manikin study of CPR using two mattress types. Resuscitation. 2011;82:1064-1070. doi: 10.1016/j.resuscitation.2011.04.003

34. Perkins GD, Kocierz L, Smith SC, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation. 2009;80:79-82. doi: 10.1016/j.resuscitation.2008.08.011



Ken Tegtmeyer

i agree with these recommendations based on the studies available. It may be most fruitful to look at provider fatigue, particularly in the out of hospital setting where number of providers to do cpr are likely lowest. Such as single person rescuer at home awaiting for EMS.


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