Survival from out-of-hospital cardiac arrest (OHCA) largely depends on the prompt actions of bystanders to intervene with cardiopulmonary resuscitation (CPR) and shocks from an automated external defibrillator (AED).[1,2] In fact, individuals who witness an OHCA event can more than double a victim’s chances of survival if they begin CPR immediately. Given the efficacy of bystander CPR, initiatives that counteract bystander hesitation and promote action are essential for improving historically low rates of OHCA survival.
Fear of infectious exposure is known to facilitate bystander resistance to performing CPR. This public concern, in part, motivated the American Heart Association (AHA) to begin recommending hands-only CPR without rescue breaths as a suitable alternative to traditional CPR in 2008. Now, during the COVID-19 pandemic, fear of infection is a ubiquitous public reality that underscores daily life. Avoiding physical proximity, wearing masks to reduce viral transmission, and other practices are becoming embedded in the public consciousness as we collectively work to curb this pandemic. The implications of this new reality have logically prompted concerns surrounding bystander inaction in response to OHCA. Both OHCA data and surveys of public opinion have reinforced the legitimacy of these concerns.[6,7] Comparison of OHCA events in Paris, France between the same weeks (March 16th to April 26th) in 2012-2019 versus 2020 demonstrate a significant decrease in the proportion of patients receiving bystander CPR during the COVID-19 pandemic (63.9% in 2012-2019 versus 47.8% in 2020). Additionally, a survey of the public capturing 1,360 participants from 26 countries reports that respondents were less willing to check for breathing or a pulse, perform chest compressions, provide rescue breaths, and use an AED during the pandemic.
These observations of bystander inaction and hesitation are particularly concerning given that OHCA appears to be on the rise. Data from New York show that the incidence of non-traumatic OHCA was 3 times higher in 2020 than during the same period in 2019 (47.5/100,000 in 2020 versus 15.9/100,000 in 2019). This concerning trend has been, in part, attributed to the secondary myocardial injury and ventricular arrhythmias resulting from COVID-19 and its treatments.
Simply put, this simultaneous increase in OHCA and decrease in bystander CPR presents a troubling situation for cardiac arrest survival. We sought to bring the perspectives of CPR instructors into this conversation. These educators are not only passionate advocates for resuscitation but also have a deep and practical understanding of bystander psychology. We surveyed these individuals to evaluate course adaptation, changes in training volume, and instructor concerns to ultimately better understand the current state of CPR/AED education during the COVID-19 pandemic.
We collected 393 responses to a 16-question survey between 9/10/2020 and 10/9/2020. Of the 393 responses, we excluded 56 for either having no answers (n=52) or no previous CPR instruction experience (n=4) leaving 337 study participants. The survey was shared via email outreach and social media networks. Multiple-choice questions were leveraged to assess current CPR instructor teaching practices and opinions.
Of the 337 CPR instructors surveyed, we engaged a relatively even distribution of instructors from the northeastern (n=75, 22%), western (n=99, 29%), midwestern (n=86, 22%), and southern (n=75, 26%) United States. Two additional respondents (1%) primarily provide CPR/AED instruction in Canada. The majority of participants teach American Heart Association curricula (n=237, 70%) followed by the American Red Cross (n=57, 17%), HSI (n=20, 6%), ASHI (n=6, 2%), and other (n=17, 5%). The sample was largely comprised of experienced instructors with 59% of respondents having taught CPR/AED courses for over 10 years.
74% of surveyed CPR instructors expressed significant levels of moderate or strong concern regarding bystander inaction in response to OHCA during the pandemic (Figure 1). To further explore the reasons for this concern, we gained qualitative insights from 200 instructors and distilled those comments to generate a graphic based on the approximate prevalence of key terms and themes (Figure 2). The most commonly cited concerns were permutations of the following: fear of infection, resistance towards touching strangers, and elevated levels of preexisting bystander reluctance. The COVID-19 pandemic has also contributed to striking decreases in instructor training volume with 73% of respondents reporting that they are training fewer students. Of this cohort, 52% of instructors report having lost over half of their pre-pandemic student volume (Figure 3).
Of the CPR instructors surveyed, 82% are currently teaching courses while 18% are not. Of those not teaching, 53% have stopped due to the COVID-19 pandemic. Only 2% of active instructors provide exclusively online instruction, and in-person training remains the most prevalent course offering provided by 83% of active instructors (Table 1).
For active instructors, 97% indicate that they have adapted their courses with new safety protocols and instruction styles while 3% have made no such changes. Social distancing (n=256, 92%) followed by additional cleaning protocols (n=236, 85%) are the most frequent course adaptations. Although 30% of instructors indicate that they have begun offering new virtual training, the majority of respondents indicate that they have not seen an increased interest in online CPR education (Figure 4). There is also concern among instructors about the ability to offer in-person training safely and online training effectively (Figure 5, 6). These findings indicate the value of blended learning courses, currently offered by 63% of active instructors, that integrate online instruction with abbreviated, in-person skills practice at a later date (Table 1).
With respect to CPR training, decreases in training volume during the pandemic merit discussion and further investigation. The observed 57% of instructors who presently train less than 50% of the pre-pandemic student volume naturally prompts concern regarding the maintenance and growth of our CPR-trained bystander citizenry. While this decrease in volume may partially result from interim certification extensions, further characterization of such dramatically reduced training volume by numbers and types of students would be valuable. Additionally, attitudes on willingness to pursue CPR instruction during the pandemic is warranted as certifying organizations and instructors work to adapt their courses.
As we empower bystanders to act, it is essential to acknowledge that CPR/AED training has a motivating effect on students’ willingness to attempt CPR during an emergency, even in the context of the COVID-19 pandemic. Researchers in Russia found that when 5062 participants completed a massive open online BLS course during the month of April, there was a significant increase (p<0.001) in the average level of readiness to attempt resuscitation and the proportion of trainees who expressed high levels of willingness to perform CPR. These findings were consistent with data from the month of April in 2019, before the pandemic, suggesting the continued benefit of training on bystander motivation to perform CPR. Therefore, as CPR training presently decreases in volume, the need for safe, effective, and adaptable courses remains urgent to educate and empower bystanders to act.
Alongside the continued importance of training, CPR instructors call for bystanders to take action in response to cardiac arrest with appropriate precautions. A 1360 participant survey from researchers at the University of British Columbia found that, although individuals expressed decreased willingness to perform the essential steps of CPR during the COVID-19 pandemic, these concerns were ameliorated if simple personal protective equipment (PPE) was available.7 AHA interim CPR guidelines for bystanders and our surveyed instructors alike note the importance of PPE in rescuer safety. Surveyed instructors also indicate that hands-only CPR must be central to bystander empowerment messaging This sentiment aligns with an observed 19.5% and 5.5% decrease in willingness to provide rescue breaths for a stranger or family member respectively during the pandemic.
Additional research is also warranted to better understand bystander risk and, when appropriate, reduce bystander fear. Researchers at the University of Washington tested for the prevalence of COVID-19 in OHCA cases and approximately 10% of victims were COVID-19 positive. Assuming a 10% transmission rate and a 1% mortality rate, 1 in 10,000 rescuers may die from COVID-19 while bystander CPR saves over 300 lives per 10,000 OHCA patients. Further research on prevalence and transmission is warranted to better understand how CPR informs rescuer risk compared to victim benefits.
The current findings support continued, adapted training as well as clear messaging for bystanders rooted in safety and empowerment. Limitations of this research include a lack of information regarding the student population or size of surveyed instructors as well as sampling bias and acquiescence bias.
Discussion Regarding Training of CPR During Covid-19
We surveyed 337 CPR instructors to understand the influences of COVID-19 on their current courses and opinions regarding bystander action. Overall, we found the majority of educators experience either moderate (34%) or strong (40%) concern regarding bystander inaction in response to OHCA. Especially in the context of increasing OHCA prevalence, bystanders remain as important as ever for survival. CPR educators are skilled at empowering bystanders to act, and therefore, insights from this cohort are valuable as we, in the words of University of Colorado resuscitation scientist Dr. Sarah Perman, “must be prepared to educate and empower rescuers in our new normal.”
Considering how to educate and empower in this new normal, CPR educators stress two key points: the continued importance of training and bystander action with appropriate precautions. These ideas are reflected in the qualitative insights obtained from 337 instructors when asked “What do you want prospective students to know about CPR and training during the COVID-19 pandemic?” As seen in a graphic created to represent the approximate frequency of key terms and themes, instructors want to impress upon their students that taking action, by both preparing for and responding to cardiac arrest, remains essential (Figure 7).
- Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2015;372(24):2307-2315.
- Capucci Alessandro,Aschieri Daniela, Piepoli Massimo F., Bardy Gust H., Iconomu Efrosini, Arvedi Maurizio. Tripling Survival From Sudden Cardiac Arrest Via Early Defibrillation Without Traditional Education in Cardiopulmonary Resuscitation. Circulation. 2002;106(9):1065-1070. doi:10.1161/01.CIR.0000028148.62305.69
- Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes. 2010;3(1):63-81. doi:10.1161/CIRCOUTCOMES.109.889576
- Sasson Comilla,Meischke Hendrika, Abella Benjamin S., et al. Increasing Cardiopulmonary Resuscitation Provision in Communities With Low Bystander Cardiopulmonary Resuscitation Rates. Circulation. 2013;127(12):1342-1350. doi:10.1161/CIR.0b013e318288b4dd
- Perman Sarah M. Overcoming Fears to Save Lives.Circulation. 2020;142(13):1233-1235. doi:10.1161/CIRCULATIONAHA.120.048909
- Marijon E, Karam N, Jost D, et al. Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study.Lancet Public Health. 2020;5(8):e437-e443. doi:10.1016/S2468-2667(20)30117-1
- Grunau B, Bal J,Scheuermeyer F, et al. Bystanders are less willing to resuscitate out-of-hospital cardiac arrest victims during the COVID-19 pandemic. Resusc Plus. 2020;4:100034. doi:10.1016/j.resplu.2020.100034
- Lai PH, Lancet EA, Weiden MD, et al. Characteristics AssociatedWith Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City. JAMA Cardiol. 2020;5(10):1154-1163. doi:10.1001/jamacardio.2020.2488
- Edelson Dana P., Sasson Comilla, Chan Paul S., et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and NeonatesWith Suspected or Confirmed COVID-19. Circulation. 2020;141(25):e933-e943. doi:10.1161/CIRCULATIONAHA.120.047463
- Birkun A. Distant learning of BLS amid the COVID-19 pandemic: Influence of the outbreak on lay trainees’ willingness to attempt CPR, and the motivating effect of the training. Resuscitation. 2020;152:105-106. doi:10.1016/j.resuscitation.2020.05.023
- Sayre Michael R., Barnard Leslie M., Counts Catherine R., et al. Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest.Circulation. 2020;142(5):507-509. doi:10.1161/CIRCULATIONAHA.120.048951