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Decreased pre-EMS CPR during the first six months of the COVID-19 pandemic

      The effectiveness of CPR prior to the arrival of professional rescuers in improving out-of-hospital cardiac arrest outcomes is virtually irrefutable.
      • Ritter G.
      • Wolfe R.A.
      • Goldstein S.
      • et al.
      The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims.
      The initiation of CPR by bystanders or family members (pre-EMS CPR) mitigates oxygen starvation in the brain and heart and helps fulfill the second component of the cardiac arrest chain of survival.
      • Nolan J.
      • Soar J.
      • Eikeland H.
      The chain of survival.
      Pre-EMS CPR requires individuals adequately trained in CPR being both available and willing to assist an out-of-hospital cardiac arrest victim. Many have speculated that the COVID-19 pandemic could dramatically lower rates of pre-EMS CPR – perhaps, because bystanders might worry about contracting COVID-19.
      • Sayre M.R.
      • Barnard L.M.
      • Counts C.R.
      • et al.
      Prevalence of COVID-19 in out-of-hospital cardiac arrest: implications for bystander cardiopulmonary resuscitation.
      • Perman S.M.
      Overcoming fears to save lives: COVID-19 and the threat to bystander CPR in out-of-hospital cardiac arrest.
      To examine if rates of pre-EMS CPR changed during the early stages of the COVID-19 pandemic, we queried the National Emergency Medical Services Information System (NEMSIS), a database of millions of EMS calls. Inclusion criteria were cardiac arrest calls where providers documented if pre-EMS CPR was provided. We specifically compared cardiac arrest calls during April to August of both 2019 and 2020. Months in 2019 served as a non-pandemic control sample, while months in 2020 represented early stages of the pandemic.
      A total of 672,691 cardiac arrests met inclusion criteria. When compared with 2019, there were more cardiac arrests in 2020 across all months, and rates of pre-EMS CPR were significantly lower in 2020 across all months (p < 0.001) (Fig. 1). Averaging cardiac arrests across all months, we noted a 8.94% reduction in the incidence of pre-EMS CPR between 2019 and 2020. Individual months’ differences were also found to be statistically significant (p < 0.001). The greatest reduction in pre-EMS CPR took place for July (−10.4%), while the shallowest reduction took place in August (−7.3%).
      Fig. 1
      Fig. 1Shows the significant reductions in rates of pre-EMS CPR when comparing March through August in 2019 and 2020. Months during non-pandemic times (2019) were associated with fewer cardiac arrests and, more importantly, significantly higher rates of pre-EMS CPR (p < 0.001).
      These data show significant reductions in the rates of pre-EMS CPR took place during the first six months of the COVID-19 pandemic. Two hypotheses behind these reductions include: bystanders might be less willing to perform CPR on cardiac arrest victims out of fear of being exposed to COVID-19 or cardiac arrest victims might be less likely to be in a public location where a trained individual might be able to intervene during a pandemic. The increased number of cardiac arrests might be due to individuals hesitating to seek medical attention and experiencing worse outcomes. Our findings align with many pandemic-specific trends that have been previously reported, including an increase in cardiac arrests and poorer outcomes.
      • Singh S.
      • Fong H.K.
      • Mercedes B.R.
      • Serwat A.
      • Malik F.A.
      • Desai R.
      COVID-19 and out-of-hospital cardiac arrest: a systematic review and meta-analysis.
      One explanation for the poorer cardiac arrest outcomes that have been reported could be significant decreases in pre-EMS CPR. Further research should seek to better understand why individuals might be concerned to perform pre-EMS CPR during a pandemic and ways to mitigate pathogen transmission during pre-EMS CPR and, as always, urgent efforts should be directed at improving the availability of CPR-trained individuals.

      Funding

      None.

      Conflicts of interest

      None.

      References

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        Prevalence of COVID-19 in out-of-hospital cardiac arrest: implications for bystander cardiopulmonary resuscitation.
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        Overcoming fears to save lives: COVID-19 and the threat to bystander CPR in out-of-hospital cardiac arrest.
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        • Fong H.K.
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        COVID-19 and out-of-hospital cardiac arrest: a systematic review and meta-analysis.
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