b'42Time to First CPR and Defibrillation For patients experiencing cardiac arrest, time is the most valuable resource. Early CPR and defibrillation are the third and fourth links in the chain of survival and are most strongly associated with improved outcomes. However, timely intervention for out-of-hospital cardiac arrest patients during the era of COVID-19 presents unique challenges, such as staff shortages, isolation protocols, additional PPE procedures and limited advanced life support resources, all of which can contribute to a delay in CPR and defibrillation.The below graph (Figure 29) compares the average monthly interval between time of arrest and time of first CPR and defibrillation in 2019 and 2020 for bystander witnessed arrests. Time of first CPR denotes the time of initial cardiopulmonary resuscitation after arrest, including that provided by a bystander, first responder, or EMS personnel. Time of first defibrillation denotes the time of the first defibrillatory shock, administered by either an AED or manual defibrillator.The average time from arrest to initial CPR was approximately the same for the first quarter of 2019 and 2020. However, the average time to CPR increased between March and April of 2020 (from 6.8 to 7.7 minutes) and remained elevated compared to pre-pandemic levels for the remainder of the year, peaking in September at 8.9 minutes.Similarly, the average time from arrest to defibrillation in the first three months of 2020 closely mirrored 2019 levels and began to increase in April. Average time to defibrillation was longer in 2020 compared with 2019 for every month thereafter. These periods of longer time intervals roughly mirror periods when COVID-19 deaths were high, possibly reflective of additional strain on EMS systems and potential delays in patient care. Figure 29. Average interval from time of arrest to first CPR and first defibrillatory shock by month.'