• James Hart, J Priyanka Vakkalanka, Uche Okoro, Nicholas M Mohr, and Azeemuddin Ahmed.
• Mid America Emergency Physicians, Springfield, Illinois.
• Prehosp Emerg Care. 2025 Jan 13: 171-7.

ObjectivesSurvival from out-of-hospital cardiac arrests (OHCA) remains lower in rural areas. Longer Emergency Medical Services (EMS) response times suggests that rural OHCA survival may need to rely more on early bystander intervention. This study compares the rates of bystander Cardiopulmonary Resuscitation (CPR) between rural and urban areas and examines societal factors associated with bystander CPR.MethodsThis study was a retrospective cohort study using merged county-level data from the National Emergency Medical Services Information System (NEMSIS) sample from 2019 and 2020, the 2019 American Community Survey, and the Bureau of Health Care Workforce data. We included all adults (age ≥ 18) with OHCA who were treated by an EMS clinician reporting data to NEMSIS, with the primary exposure of OHCA rurality, and the primary outcome of bystander CPR by a member of the public. Rurality was assigned using the Rural Urban Commuting Area code associated with the OHCA location. Cases were excluded if there was an indication for witnesses identified as health care personnel, the incident occurred at a health care site, or geographical data were not available. The association between patient- and community-level covariates and bystander CPR were measured using generalized estimating equations to model the adjusted odds ratios (aOR) and 95% confidence intervals (CI), clustering on county.ResultsA total of 99,171 OHCA patients were identified and 60.9% (n = 60,380) received bystander CPR. Patients with OHCA living in isolated small rural towns (aOR: 1.57, 95%CI: 1.28-1.91) were more likely to have bystander CPR when compared to those living in urban cities. The odds of bystander CPR was lower in counties with larger populations of those without high school diplomas (e.g. >15% vs ≤6%, aOR: 0.56; 95%CI: 0.51-0.61), non-Caucasian populations (e.g. >40% vs ≤10%, aOR: 0.83; 95%CI: 0.76-0.91), and older populations (e.g. >14% vs ≤9%, aOR: 0.82; 95%CI: 0.74-0.91).ConclusionsWe observed lower rates of bystander CPR in communities with lower education, higher rates of non-Caucasian populations, and older populations. Our findings emphasize the need for public interventions in bystander CPR training to meet the needs of diverse community characteristics, and particularly in areas where EMS response times may be longer.

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