Decreased early bystander CPR initiation despite stable overall rates: a nationwide time-to-event analysis during the COVID-19 pandemic

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Out-of-hospital cardiac arrest (OHCA) (n=56082). Intervention: COVID-19 pandemic period (March 11 to December 31, 2020) vs. Pre-pandemic period (March 11 to December 31, 2019). Primary outcome: Early bystander cardiopulmonary resuscitation (BCPR) initiation within 10 minutes after a witnessed OHCA (aHR 0.96, 95% CI 0.93-0.98, p=0.010).

Q: What does this research mean for the field?

Early bystander CPR initiation within 10 minutes of witnessed out-of-hospital cardiac arrest decreased modestly during the COVID-19 pandemic despite stable overall bystander CPR rates. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Mutalov Boburjon; Tomonari Shimamoto; Yohei Okada; Takefumi Tsunemitsu; 隆太 小野寺; Norihiro Nishioka; Tomohiko Imamura; Yukiko Tateyama; Yoshimitsu Takahashi; Taku Iwami

doi:10.1016/j.resplu.2026.101531

October 15, 2026Resuscitation PlusOpen Access

Decreased early bystander CPR initiation despite stable overall rates: a nationwide time-to-event analysis during the COVID-19 pandemic

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Key result

COVID-19 pandemic linked to ~4% lower early bystander CPR initiation after witnessed OHCA.

aHR 0.96
95% CI 0.93-0.98
P=0.010
n=56,082

Figures

Why the study?

Overall bystander cardiopulmonary resuscitation rates after out-of-hospital cardiac arrest during the COVID-19 pandemic have been inconsistently reported, and the timing of initiation has received limited attention.

Does the COVID-19 pandemic period reduce early bystander CPR initiation within 10 minutes after witnessed out-of-hospital cardiac arrest in adults compared to the pre-pandemic period?

Key Points

To assess changes in bystander cardiopulmonary resuscitation initiation timing within 10 minutes following witnessed out-of-hospital cardiac arrest during the COVID-19 pandemic.
Retrospective cohort study analyzing All-Japan Utstein registry records of 56,082 adult layperson-witnessed, non-traumatic out-of-hospital cardiac arrest cases across Japan (27,770 pre-pandemic in 2019 vs. 28,312 pandemic in 2020).
Assessed bystander CPR initiation within 10 minutes of arrest witnessing as the primary outcome using Kaplan-Meier curves and multivariable Cox proportional hazards models.
Evaluated 1-month survival and favorable neurological outcome (Cerebral Performance Category 1 or 2) using multivariable logistic regression adjusted for bystander CPR timing and covariates.
Overall bystander CPR rates remained unchanged (58.7% pre-pandemic vs. 58.6% pandemic, p=0.759), but initiation within 10 minutes showed a lower hazard during the pandemic (aHR 0.96; 95% CI, 0.93–0.98; log-rank p=0.010).
One-month survival dropped from 11.4% to 9.4% (p<0.001), with the pandemic period remaining independently associated with lower survival after adjusting for CPR timing (aOR 0.86; 95% CI, 0.80–0.92).
Earlier bystander CPR was linked to progressively higher odds of favorable 1-month neurological outcome (aOR 3.27 for 0–3 min, 2.66 for 4–7 min, and 1.68 for 8–10 min, compared with >10 min).

Study Design

Type

Cohort (n=56,082)

Multicenter

Yes

Structured PICO

Does the COVID-19 pandemic period reduce early bystander CPR initiation within 10 minutes after witnessed out-of-hospital cardiac arrest in adults compared to the pre-pandemic period?

P

Population

56,082 adults in Japan (median age 80, ~40.3% female) with layperson-witnessed, non-traumatic out-of-hospital cardiac arrest and EMS resuscitation attempts, evaluated up to 1 month post-arrest.

E

Exposure

COVID-19 pandemic period (March 11 to December 31, 2020)

C

Comparator

Pre-pandemic period (March 11 to December 31, 2019)

O

Outcome

Early bystander cardiopulmonary resuscitation (BCPR) initiation, defined as initiation within 10 minutes after a witnessed OHCAsurrogate

Main Result

Hazard Ratio: 0.96 (95% CI 0.93–0.98)

Absolute Event Rate: 53.8% vs 54.4%

p-value: p=0.010

Time-to-event analysis revealed a modest delay in early bystander CPR initiation during the COVID-19 pandemic that was masked by stable overall binary CPR rates, highlighting the importance of tracking CPR initiation timing as a resuscitation quality metric.

Limitations

Timing of witnessing and initiation of BCPR was based on bystander reports and may be subject to recall bias.
Registry lacks detailed information on dispatcher recognition intervals, CPR quality, compression interruptions, and AED retrieval time.
Residual confounding by unmeasured factors (such as individual-level infection risk perception or local healthcare system strain) cannot be excluded.
Provision of dispatcher CPR instructions was recorded only as a binary indicator without timing information, and regional variation in COVID-19 guidance implementation could not be assessed.
Generalizability to other countries may be limited due to differences in EMS systems, population characteristics, and resuscitation practices.
Residual confounding by unmeasured factors (e.g., infection risk perception, healthcare system strain) cannot be excluded.
Provision of dispatcher CPR instructions was recorded without information on their timing.
Findings from a nationwide Japanese registry may have limited generalizability to other countries.

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Implication

Pandemic-associated delays in early bystander CPR may have contributed to worse OHCA survival; leaves open whether timing metrics should supplement binary rates in quality audits.

Abstract

Background: Timely bystander cardiopulmonary resuscitation (BCPR) is critical for survival after out-of-hospital cardiac arrest (OHCA). While overall BCPR rates during the COVID-19 pandemic have been inconsistently reported, BCPR initiation timing has received limited attention. This study assessed BCPR initiation within 10 min after witnessed OHCA. Methods: This retrospective cohort study used the All-Japan Utstein registry. Adults with non-traumatic, layperson-witnessed OHCA during March 11-December 31 of 2019 and 2020 were included. The primary outcome was BCPR initiation within 10 min after witnessing. Kaplan-Meier and Cox models were used for time-to-event analyses. Exploratory logistic regression examined associations between BCPR timing and 1-month outcomes. Among BCPR recipients, earlier initiation was associated with higher odds of a favorable neurological outcome at 1 month (aORs 3.27, 2.66, and 1.68 for 0-3, 4-7, and 8-10 min, respectively; reference >10 min). The pandemic period remained associated with lower 1-month survival after adjustment for BCPR initiation timing (aOR 0.86; 95% CI, 0.80-0.92). Conclusions: Although the overall BCPR rate remained unchanged during the pandemic, time-to-event analysis identified a modest reduction in early BCPR initiation. Earlier BCPR was associated with better outcomes, but differences in its timing did not fully explain the lower survival during the pandemic.

Discussion

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Cite This Study

Boburjon et al. (2026) conducted a cohort in Out-of-hospital cardiac arrest (OHCA) (n=56,082). COVID-19 pandemic period (March 11 to December 31, 2020) vs. Pre-pandemic period (March 11 to December 31, 2019) was evaluated on Early bystander cardiopulmonary resuscitation (BCPR) initiation within 10 minutes after a witnessed OHCA (aHR 0.96, 95% CI 0.93-0.98, p=0.010). The COVID-19 pandemic period was associated with a modest reduction in early bystander CPR initiation within 10 minutes after witnessed OHCA compared to the pre-pandemic period (aHR 0.96; 95% CI 0.93-0.98).

synapsesocial.com/papers/6aee6b8671a7594806220978 https://doi.org/10.1016/j.resplu.2026.101531

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Decreased early bystander CPR initiation despite stable overall rates: a nationwide time-to-event analysis during the COVID-19 pandemic

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Decreased early bystander CPR initiation despite stable overall rates: a nationwide time-to-event analysis during the COVID-19 pandemic

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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