Barriers and facilitators while implementing community first responder systems in a western setting: mixed-methods expert consensus

Abstract

Background

Early cardiopulmonary resuscitation and timely defibrillation are key determinants of out-of-hospital cardiac arrest survival. Community first responder (CFR) networks improve early response, yet adoption varies internationally. This study summarizes current key factors affecting CFR-system implementation through an international expert consensus process.

Methods

A mixed-methods design explored barriers and facilitators to CFR system development. Data were collected during an expert consensus workshop in April 2024 Hinterzarten, Germany (46 experts, 14 countries) and an online survey. Experts were invited based on previous authorship regarding CFR systems. Thematic content analysis and descriptive statistics identified recurrent themes and areas of agreement.

Results

Experts agreed on core needs for effective CFR systems with high consensus regarding locally adapted dispatch algorithms, clear privacy rules for CFR activation, sufficient CFR training, structured debriefing and psychological support. Congruence was weaker regarding funding, legal or governance frameworks, reflecting variation in responsibilities, liability, and automated external defibrillator- (AED-) registry organisation. Findings were structured around a previously developed roadmap outlining four stages of CFR-system maturation. In the exploration phase, unrecognition of delays in Basic Life Support initiation impedes translation of practice gaps into action. Installation is challenged by recruitment, funding, and coordination among stakeholders. Implementation requires outcome evaluation. Moreover, sustainability is threatened by volunteer attrition and reliance on government budgets. Supportive legal frameworks, centralised AED registries, and integration into national health initiatives facilitate both establishment and long-term stability.

Conclusion

This exploratory expert consensus process on CFR system implementation highlights the need for stable funding, coherent governance, aligned legal frameworks, comprehensive and exhaustive AED registration, data-driven feedback from practice to system optimisation and targeted training of CFR.

Background

Out-of-hospital cardiac arrest (OHCA) remains a major public health concern, with survival outcomes strongly dependent on early cardiopulmonary resuscitation (CPR) and timely defibrillation [1, 2]. With each minute delay in defibrillation of a shockable rhythm from cardiac arrest onset, the probability of survival decreases by 10% [3]. Global data on emergency medicine service (EMS) response times from national and international registries demonstrated mean response times of 12.2 min (range 6.4–22.8 min); median response times in 2021 ranged between 7 and 14 min with 25% of patients reached within 7 min [4–6]. Different systematic reviews and meta-analysis have shown that alerting community first responders (CFR) to OHCA patients is associated with higher rates of bystander-initiated CPR, increased use of automated external defibrillator (AED) before ambulance arrival, and increased survival at hospital discharge or 30 days, which highlights the significant potential of mobile applications in enhancing bystander interventions and improving patient outcomes [7, 8]. The implementation of CFR systems is therefore recommended by the International Liaison Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC), and the American Heart Association (AHA) [9–11].

Despite the current evidence and international guidelines, the implementation of CFR systems remains heterogeneous, as CFR systems are developed with varying designs and at different stages across countries and regions [12]. The positive outcomes achieved in mature systems have not yet been realised in all regions. Prior research and international conferences have highlighted multiple barriers and facilitators to implementation as well as a roadmap to implement a CFR system [8, 13–17]. To our knowledge, no studies have examined the variety of difficulties encountered on implementation of existing CFR systems internationally. The purpose of this study was to explore, and highlight key barriers and facilitators affecting the implementation, maturation, and sustainability of CFR systems for OHCA through an international expert consensus process. We report insights from experts from different countries actively involved in CFR system implementation and sustainment, by means of both a live workshop and online survey. Drawing on expert input from different international contexts may help align CFR systems across regions, moving from fragmented and isolated local implementations towards eventually coordinated transnational models.

Methods

Study design

Expert panel selection

The present study builds upon an established international consensus network in the field of CFR systems for OHCA. The expert panel and recruitment strategy are directly derived from the third international CFR Symposium (Hinterzarten, Germany, April 2024), as previously described by Metelmann and coworkers (2025) [14], which itself represents a continuation of earlier work in this domain [18]. Specifically, experts were identified using a structured and reproducible methodology combining a systematic literature search in PubMed with predefined keywords related to first responder systems and smartphone alerting, and a complementary snowballing approach to identify additional relevant researchers and research groups [18]. Corresponding authors of peer-reviewed publications were invited to participate, ensuring inclusion of individuals with a demonstrated scientific track record in the field. In parallel, experts were recruited through established professional networks, including members of the German Resuscitation Council (GRC), the European Resuscitation Council (ERC), and affiliated organizations [18]. The 2024 consensus process expanded this previously established expert network by inviting additional researchers who had published in the field in recent years [14]. The explicit aim of this approach was to include all active research groups in the domain of CFR systems, thereby ensuring broad international and multidisciplinary representation. As such, the expert panel represents a stable and evolving network of domain experts.

For the present study, a total of 46 experts from 14 countries across Europe, North America, Asia, and Australia participated. The panel comprised a multidisciplinary group with expertise in emergency medicine, cardiology, resuscitation science, epidemiology, and digital health, as well as practical experience in the implementation and evaluation of CFR systems [14]. Despite efforts to ensure broad geographical representation, certain regions, including Eastern Europe, South America, and Africa, remained underrepresented, likely reflecting publication bias and the limited identification of active research groups in these areas [14]. As no additional inclusion criteria were applied in the present study beyond those established in the preceding consensus initiatives, expertise was defined implicitly through prior selection into this international network, based on (i) authorship of peer-reviewed publications in CFR systems or OHCA, (ii) active involvement in system development, implementation, or evaluation, and/or (iii) affiliation with relevant national or international resuscitation organizations.

Study development and validation

For this study, real-life voting, open discussion and an online questionnaire were developed as part of a structured, exploratory multi-step consensus process embedded within the third international CFR Symposium (Hinterzarten, Germany, April 2024).

Real life voting and development of the online questionnaire was performed on statements based on (i), previously published work on the development of CFR systems [17], (ii), informed by consensus terminology [18], and (iii), for the online questionnaire, considering also emerging topics and unresolved discussions identified during the consensus initiatives. A pre-workshop discussion involving representatives from CFR systems in Belgium and Italy (March 2024) was conducted to refine and structure CFR barrier and facilitator’ themes [17] into preliminary real life voting statements. During the symposium workshop, these pre-defined statements were presented, clarified if needed before actual voting. This real-time expert appraisal ensured content and form validity of the voting statements. In contrast to traditional survey-based research, the questionnaire was designed to complement the consensus process by serving as a post-workshop validation and triangulation tool. The survey items were directly informed by the consensus discussions and voting outcomes, reflecting a consensus-driven development process. Formal pilot testing was not performed; however, iterative refinement through expert input functionally replaced this step by ensuring that all items were pre-vetted within the target expert population. The survey was used to quantify agreement, capture additional contextual insights, and assess the robustness of the workshop findings within a convergent parallel mixed-methods design. The approach enabled a comprehensive assessment of barriers and facilitators to CFR system implementation, in line with established mixed-methods methodology [19], and reported according to the CRISP statement for primary care [20]. All participants took part voluntarily, provided informed consent, and no patient data were involved.

Data collection

Qualitative data during life discussions were captured through detailed note-taking during the discussions (ME, VS). The degree of consensus for each statement was assessed using anonymous real-time voting (PINGO, University of Paderborn, Germany). Following the symposium, the voluntary online questionnaire (Qualtrics, Seattle, WA, USA, Appendix 1) was distributed to all eligible participants (n = 44), 12 weeks after the workshop, with one reminder sent after 5 weeks. Two members of the study team (ME, DE) were excluded from participation to minimise bias. The survey included both factual system-level questions (e.g., legal frameworks, AED registration practices) and opinion-based items, reflecting expert perspectives. The themes were grouped around two major parts (1), Legal Framework and Practice-policy Connections and (2), Roadmap for CFR Implementation (covering the four stages exploration, installation, implementation and sustainment of CFR systems [17]. No incentives were provided.

Data analysis and reporting

Qualitative data from workshop notes were grouped into workshop highlights using thematic content analysis. Consensus voting thresholds were defined a priori (≥75% agreement) in line with the median threshold reported in consensus methodology review [21]. Answers were classified as Fully agree (5), Agree (4), Neutral (3), Disagree (2), Fully Disagree (1).

Open-ended questionnaire responses were analysed using a descriptive aggregation approach, rather than a full qualitative thematic analysis, given the exploratory nature of the questionnaire and the limited number of responses per item. Responses were read by two separate researchers from the Belgian network with both a medical doctor background, in full, and grouped into descriptive categories reflecting reported barriers and facilitators. Open-ended responses were de-identified prior to reporting. The conclusions per thematic area are reported and not in repetition of the workshop’s discussion.

Results

Workshop highlights

Key domains of CFR systems raised as workshop highlights during group discussion, exemplified by illustrative quotes (Table 1)

Table 1.

Thematic overview of barriers and facilitatorsfor community first responder systems as derived from workshop highlights

Theme	Highlights	Illustrative Quote*
Demographics, Geographics, and EMS Landscape	• Dispatch algorithms must account for regional variations (e.g., mountainous vs. urban settings). • “Black spots” persist with few CFR/AED; • In-building (e.g. Wi-Fi-based) geolocation and navigation remain costly and suboptimal.	“High-rise environments continue to pose major challenges, with vertical navigation not yet sufficiently implemented.” “There is a need for affordable integration of advanced geolocation solutions.”
Privacy	• Anonymisation is typically maintained but operational needs may justify limited disclosure.	“Two-way communication with dispatchers may require lifting anonymity in certain cases.”
Campaign & recruitment	• Motivation is fostered by community identity, ongoing training, recognition awards; • Tiered qualification models select dedicated CFR based on activity; • (Predictive) machine learning models reduce unnecessary alerts mitigating alert fatigue.	“Volunteers are motivated by the opportunity to ‘give back’ and by becoming mentors.”
Aftercare	• Lack of structured psychological support risks attrition.	“Responding to OHCA can be traumatic and requires structured psychological support.”

* Illustrative quotes are paraphrased from discussion notes

EMS: Emergency medical service, AED: Automated external defibrillator, OHCA: Out-of-hospital cardiac arrest, CFR: Community first responder

Consensus voting

Consensus statements achieved agreement across all participants (Table 2), using a threshold of 75%.

Table 2.

Thematic overview of consensus statements and agreement levels as derived from real-life voting. Colour dark green is used for above 90% consensus, green for 80 to 89% consensus and light green for 75 to 79% consensus

EMS: Emergency medical service, CFR: Community first responder

Online questionnaire

Twenty out of the forty-four participants (or 45%) responded to the online questionnaire consisting of legal framework analysis (a) and roadmap development (b), representing 11 of the 14 participating countries (or 79%). Thematic analysis, not included in the results of the workshop highlights and consensus voting, revealed novel information:

Legal framework – development and sustainability

Experts reported multiple legal and governance barriers:

• Absence of AED registries: AED-registration difficulty was explicitly reported in three countries, next to the absence of a central or continuously updated registry or owner-restricted AED databases, limiting coordinated deployment. In two countries a national registry and no problems were reported.

• Unclear maintenance rules: Maintenance responsibilities and reimbursement gaps were explicitly reported in four countries, including lack of financial coverage for used defibrillation pads and unclear ownership obligations.

• Liability and insurance concerns: Private AED ownership was reported as problematic due to legal uncertainty and fear of liability; AED cabinets have been reported legally classified as “buildings”, requiring lengthy approval processes.

• Ambiguity of legal protections: Uncertainty persists regarding whether “Good Samaritan” protections cover CFR immunity, patient safety, or mandatory insurance.

• Governance fragmentation: Governance fragmentation was reported in three countries, whereas explicit concerns about limited political awareness or prioritisation were raised in two countries. In these settings, misalignment between administrative levels and insufficient political commitment were perceived as major barriers to system development.

Experts reported multiple legal and governance facilitators:

• Clear legislation on liability protection: Examples such as the Good Samaritan Law [22] providing a positive framework supporting CFR.

• Public education: Examples such as Singapore’s nationwide public-education effort ‘Save-A-Life’ initiative [23], jointly promoted by the Singapore Civil Defence Force, the Ministry of Health, the Singapore Heart Foundation and the People’s Association.

• Clear ownership: Examples such as Denmark, where AED accessibility depends on owners, with only a limited number of devices being locked or inaccessible.

• Local embedment: Examples such as Belgium, with municipal involvement through local Red Cross training initiatives and active clearly defined local steering committees.

General facilitating mechanisms included outsourcing AED registration, regular stakeholder meetings, harmonised (inter-)national legislation and cooperation, next to governance awareness and prioritisation including governmental funding.

Roadmap – exploration to sustainability

Discussing development of CFR systems from a roadmap-based perspective [17], several phase-specific barriers and facilitators were proposed (Table 3).

Table 3.

Thematic overview of barriers and facilitators across the four implementation phases of CFR systems development as derived from online questionnaire responses. Categories are not mutually exclusive, and individual responses may contribute to multiple phases

Phase	Barriers	Facilitators
Exploration	• Low scientific evidence-level limits political support and funding. • Stakeholders sometimes poorly informed about cardiac arrest and its impact.	• Identification of ‘black spots’ in EMS coverage or low OHCA survival. • International guidelines and position statements facilitating adoption.
Installation	• Financing gaps and local bureaucratic hurdles. • Resistance/lack of awareness from AED owners to register devices.	• Stable funding, especially when responders are dispatched with AEDs. • Broad stakeholder networks and governmental coordination supporting installation.
Implementation	• Improved survival outcomes unrealistic as short-term indicators. • Underuse of feedback forms and steering committees. • Limited implementation restricting meaningful evaluation.	• Use of intermediate outcome measures (e.g., bystander CPR rates, AED use) proposed as more realistic indicators.
Sustainability	• Active CFR retention may be more difficult than recruitment: High CFR attrition. • Difficulty ensuring operational sustainability (lack of political prioritisation or unstable funding). • Absence of nationwide expansion, existence of different separate local systems.	• Integration into regional/national health initiatives • Recognition that (supra-) national governmental awareness and funding are equally necessary for long-term viability

EMS: Emergency medical service, OHCA: Out-of-hospital cardiac arrest, AED: Automated external defibrillator, CPR: Cardiopulmonary resuscitation

Discussion

The implementation of CFR systems is increasingly recognised as a key determinant of early intervention and survival in OHCA [24]. In-person meetings between international CFR systems’ stakeholders and experts previously facilitated structured exchange of practical solutions to implementation challenges and evidence-informed consensus processes [14, 18, 25–27]. This report aimed to document on discussions and consensus voting by global experts in the field of CFR systems development regarding main barriers and facilitators of CFR system development. Divergences between qualitative and quantitative findings were not identified, granularity behind the consensus agreement and discussions during the workshop are provided.

Demographics, Geographics, and EMS Landscape

Environment-aware dispatch algorithms

Geography and urban environment strongly shape CFR systems’ effectiveness. CFR schemes were initially designed to support ambulance services in rural settings, where EMS arrival can be delayed [28]. Despite lower volunteer density in such areas, smartphone-based CFR often arrived faster than EMS in rural, sub-rural, and suburban contexts [29–31]. CFR dispatch and the strategic relocation AED using terrain-sensitive modelling in mountainous areas, where EMS response is delayed, have demonstrated measurable improvements in AED and CFR coverage [32]. High-rise environments pose specific challenges: vertical distance, elevator availability, access restrictions all introduce delays and complicate high-quality CPR delivery [33]. Pragmatic solutions included integration of (handset) z-axis data at public-safety answering points (PSAP), digital floor plans, controlled entry (e-keys or concierge integration or building access codes), and dispatching responders already present inside buildings where conventional GPS does not work effectively [34].

Legal frameworks and privacy

Consistent legal framework

The integration of CFR systems with EMS have often raised governance and privacy concerns. Advanced Mobile Location (AML) enables the automatic transmission of EMS callers’ geolocation directly to PSAPs under the General Data Protection Regulation (GDPR) ‘public interest’ legal basis, ensuring that data are securely stored, not disclosed to third parties, and retained according to legal requirements. Operationally, once a CFR accepts an alert, typically geolocation and sometimes contact details are processed for routing and dispatcher interaction. This constitutes identified processing but accordingly remains legally permissible under strict purpose limitation. Systems have enabled dispatcher–CFR communication or selective disclosure, such as live video from bystanders in Scandinavian systems, which improved medical assessment and CPR quality [35]. CFR applications further typically employ privacy-by-design measures, such as legal contracts with role-based access, pseudonymisation of CFR data, and separation of identifiers from location streams. Systems have maintained separate servers for CFR identity, data and live geolocation, reducing re-identification risk and aligning with GDPR principles (evapp.org). Legal assessments could help establish the foundation for policy development and app implementation [36].

Recruitment, campaigns, and retention

Comprehensive training program

Volunteer motivation and retention have been linked to intrinsic drivers such as altruism, autonomy, and community identification [37]. Responders with prior CPR experience or medical training are more likely to accept alerts and provide care, suggesting targeted recruitment of these groups could strengthen system reliability [38]. CFR are further engaged by support of peers and society [39]. Systems have used symbolic recognition initiatives, such as honorary titles for responders in Ticino [17], to reinforce motivation and social identity. The Dutch system HartslagNu further provided an example of pragmatic recruitment and retention strategies: by removing 80 000 inactive accounts and collaborating with over 100 local organisations, the platform ensured that the network remained both operationally robust and socially embedded [40, 41].

Psychological aftercare

Structured debriefing and psychological support

The psychological impact of responding to OHCA alerts has been reported as manageable, with CFR describing the experience as intense but positive, with low prevalence of post-traumatic stress in follow-up assessments [42–45]. International guidelines [46] and existing CFR systems indeed recognise the need for aftercare and have included different strategies for follow up. Multi-tiered programs have been developed incorporating customised training, structured debriefings, and proactive follow-up with the CFR after missions to assess their need for professional psychological support [47].

Roadmap

Harmonised responsibilities, liability, and awareness

The development of CFR systems appears to follow recurring barriers and facilitators across the four phases, from exploration to implementation. Regarding the exploration phase, “black spots” in timely EMS arrival still exist [5, 6]. However, limited scientific evidence and low political awareness continue to be used as arguments to undermine support and funding. Findings from the expert questionnaire conducted for this study reflect these concerns. The international position statements and guidelines for CFR systems by the ERC, the ILCOR and AHA [9–11] should eventually facilitate broader adoption. During the installation phase, recruitment of CFR was reported by the experts and in literature to be generally successful [48], but long-term active retention may seem more problematic. Stable financing and integration into existing EMS networks are repeatedly highlighted as prerequisites, while suboptimal AED registration has been noted as a barrier to system maturation. In the implementation phase, intermediate outcomes such as bystander CPR and AED use provide actionable milestones. Long-term viability ultimately depends on dual recognition: both governmental awareness and secured, if needed, funding, enabling a more optimal use of the yet existing community resources.

Different cost-effectiveness modelling studies on CFR systems have been performed [49–52], generally demonstrating that CFR systems, according to the current data, could achieve favourable cost-effectiveness ratios per quality-adjusted life year (QALY). This may be because CFR systems leverage existing potential more efficiently than systems that rely solely on professional EMS [52]. Embedding CFR in national health policy enabled progress, contrasting with the lack of structural support elsewhere. Different regions have systems of varying maturity, organisational models, and financial structures, ranging from profit-driven enterprises to volunteer-based or non-governmental-based initiatives. Systems have often developed independently, with limited coordination across borders or sectors [27]. From a societal and patient-centred perspective, such fragmentation may risk inefficiency and constrain collective learning. The challenge ahead may be to envision CFR initiatives not as isolated solutions, but as interoperable components of a broader ecosystem in which integration, cross-border collaboration, and maybe shared governance may ultimately maximise survival and equity in OHCA response.

This study has several limitations. Although the expert panel included a broad international representation, participation in the online survey was voluntary and yielded a 45% response rate, introducing the possibility of non-response bias. Open-ended survey responses limited in number did not allow for in-depth qualitative analysis and data should thus be interpreted as exploratory and descriptive. Countries were represented by varying numbers of experts, reflecting differences in CFR system maturity and stakeholder structures, due to the real-world setting, rather than a stratified sampling strategy. As a result, comparisons between countries may disproportionately reflect systems with more active contributors rather than population-based national estimates. The latter limitation existed in previously published consensus work consisting of the same experts [14, 26]. Despite the large variety in systems, consensus was high. The questionnaire was in English which may have led to language bias. The questionnaire was not pilot tested, however, was informed by previous consensus work and real-life discussions during the consensus workshops. Expert input reflects self-reported experiences and perceptions, which may be influenced by recall or personal involvement in system development. This subjective component may have strengthened the qualitative richness but limits generalisability. The workshop discussions were documented through note-taking and structured thematic analysis, rather than full audio transcription, which may have reduced the granularity of qualitative data. The analysis did not incorporate patient-level outcomes or objective system performance metrics for each CFR system. Consequently, conclusions relate to expert-reported barriers and facilitators rather than empirically measured effectiveness. Finally, the study team acted both as authors and participants; this dual role may have introduced interpretative bias in theme selection and framing.

Conclusion

The consensus of international experts on community first responder systems emphasises a need for stable funding, governance, coordinated legal frameworks, complete AED registration, data-driven feedback, targeted training, and policy integration. The highest consensus was found for the statement that there is a need to define conditions on alerts (privacy and safety) in CFR systems. Further research should optimise coverage, indoor navigation, high-rise response and integration of systems, potentially into nation-wide systems to maximise patient survival in all regions. Integration of these insights with objective system performance data and expansion to underrepresented regions should further strengthen global applicability.

Online survey

What FRS do you represent?

Where is the FRS based (country)?

What is your background?

Theme 1: legal framework and practice-policy connections

Are you aware of the current legal frameworks in your country regarding the use of automated external defibrillators (AEDs) by first responders? (NO/YES/UNSURE)

Do you feel that the current legal frameworks adequately support first responders? (STRONGLY AGREE, AGREE, NEUTRAL, DISAGREE, STRONGLY DISAGREE)

Are there legal protections in place for first responders who perform CPR or use an AED during an emergency? (YES/NO/UNSURE)

Have you encountered legal difficulty that hinder the implementation of AED programs in your area? (HIGH DIFFICULTY/DIFFICULTY/NEUTRAL/SLIGHT DIFFICULTY/NO DIFFICULTY AT ALL/NO EXPERIENCE)

Could you provide a short summary of the legal difficulty if applicable? What were the barriers and facilitators? (OPEN)

Could you provide a short summary of the practice-policy connection difficulty if applicable? What were the barriersand facilitators? (OPEN)

Is there any legislation (initially) limiting/facilitating the introduction of FR systems in your country or region? (E.g. Can the EMS dispatcher call on non-medical volunteers, Are lay people allowed to use AED?,.) (YES/NO/PARTLY)

Would additional legal reforms improve the efficacy of first responders in cardiac arrest situations? (STRONGLY AGREE/AGREE/NEUTRAL/DISAGREE/STRONGLY DISAGREE)

In which way is (lack of) governemental awereness/investment impeding or facilitating the development and expansion of FR systems in your country or region? (OPEN)

Theme 2: roadmap on developing a FRS – ONLINE SURVEY

For the second theme, we would like to request your feedback on the roadmap figure published by Moens et al. (2023):

Moens E, Degraeuwe E, Caputo Maria L, Cresta R, Arys R, Van Moorter N, Tackaert T, Benvenuti C, Auricchio A, Vercammen S. A roadmap to building first responder networks: Lessons learned and best practices from Belgium and Switzerland. Resusc Plus. 2023 Sep 25;16:100469. doi: 10.1016/j.resplu.2023.100469. PMID: 37779882; PMCID: PMC10539931.

Could you provide a short summary in which phase the highest difficulty was/is applicable? What were the enablers and facilitators? (OPEN)

Exploration phase

Are you aware of any “black spots” in EMS coverage or areas with low survival rates for out-of-hospital cardiac arrest (OHCA) in your region? (YES/NO/UNSURE)

Are there effective advisory bodies in emergency medicine in your country that contribute to policy development? (YES/NO)

Are local steering committees actively involved in improving first responder networks in your area? (YES/NO/UNSURE)

Do you have further comments on the Exploration Phase? (OPEN)

Installation phase

Is there effective cooperation between private and public AED programs and first responder operations in your region? (YES/NO/UNSURE)

Are there sufficient campaigns, financing, and recruitment efforts to support first responder readiness in your area? (YES/NO/UNSURE)

Do you believe the current recruitment strategies are effective in attracting and retaining first responders? (STRONGLY AGREE/AGREE/NEUTRAL/DISAGREE/STRONGLY DISAGREE)

Are feedback forms and steering committees effectively used to ensure the quality of first responder programs? (YES/NO/UNSURE)

Do you have further comments on the Installation Phase through your experience? (OPEN)

3&4. Implementation phase

How would you rate the overall improvement in cardiac arrest outcomes since implementing the new strategies? (EXCELLENT/GOOD/FAIR/POOR)

Is there frequent and relevant stakeholder engagement to sustain the practice-policy loop in your region? (YES/NO/UNSURE)

Do you have further comments on the Implementation Phase through your experience? (OPEN)

Author contributions

VS was as coordinating author responsible for the conception and design of the article. ME, DE and CML were responsible for the acquisition, analysis and interpretation of all data. ME has further on drafted the first version of the article. Valuable feedback was gathered from all authors during several feedback rounds. All authors have read and approved the final manuscript.

Funding

None of the authors have any financial implications with the study. The symposium was sponsored by the German Resuscitation Council (GRC), the German Heart Foundation, and the ADAC Foundation.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable.

Competing interests

E. Degraeuwe – Executive member of the EVapp NGO and shareholder of Prior-IT BV; E. Baldi – Member of ERC Research-NET, ESCAPE-NET, and COST Action PARQ; T. Barry – Chair of the Pre-Hospital Emergency Care Council in Ireland; B.W. Böttiger – Member of the German Resuscitation Council (GRC), Treasurer of the ERC, and advisor to the German Red Cross; H.J. Busch – Vice-chair of Region of Lifesavers and member of the GRC; A.A. Doshi – Recipient of AHA, Hillman Foundation, and PEMF grants, and board member of the Sudden Cardiac Arrest Foundation and the Cardiac Arrest Survivors Association; J. Ganter – Board member of Region of Lifesavers; R. Greif – ERC Director of Guidelines and ILCOR; chair of the ILCOR Education, Implementation and Teams Task Force, and member of the Editorial Board of Resuscitation Plus; F.L. Henriksen –Co-developer of the FirstAED GPS technology; B. Metelmann – Member of the ERC Guidelines 2025 “Systems Saving Lives” Writing Group; C. Metelmann – Member of the ERC Guidelines 2025 “Systems Saving Lives” Writing Group; K.G. Monsieurs – Recipient of Laerdal Foundation and Zoll Foundation grants, and Editor-in-Chief of Artificial Intelligence in Emergency Medicine; M.P. Müller – Chair of Region of Lifesavers and executive member of the GRC; J.S. Pooth – Employee of Resuscitec GmbH, GRC Executive Committee member, and recipient of HEROES study funding from the German Heart Foundation; S. Prasse – Managing Director of Mobile Retter e.V.; A. Scapigliati – President of the Italian Resuscitation Council; S. Schnaubelt – Member of the ILCOR EIT Task Force, ERC ALS SEC, and Vice-chair of the Austrian Resuscitation Council; T. Scquizzato – Social Media Editor of Resuscitation Plus; P. Shahriari – Recipient of TrygFonden research grants; H.L. Tan – Chair of COST Action PARQ; S. Vercammen – President of the EVapp NGO and shareholder of Prior-IT BV; D.D. Salcido – Recipient of AHA, Hillman Foundation, and PEMF grants, board member of the Sudden Cardiac Arrest Foundation, and Advisory Group member of the Cardiac Arrest Survivors Association; D. Fredman – Co-founder of the Heartrunner Community First Responder system. E. Moens, M.L. Caputo, R. Cresta, J. Bray, S. Cheskes, C.D. Deakin, M.M. Ekkel, D. Elschenbroich, L. Gamberini, C.J. Jagtenberg, M. Jonsson, M. Khalemsky, T. Marks, W. Ming, N. Schittko, S.S. Scholz, P. Snobelen, R. Stieglis, B. Strickmann, K.C. Thies, G. Trummer, W.A. Wetsch have no COI to declare.