Authors from Lombardy, Italy, 1 and Paris, France2 have recently reported an increase in the incidence of out-of-hospital cardiac arrest (OHCA), suggesting a direct or indirect effect of COVID-19. As hypothesized, 3 fewer patients received bystander-initiated cardiopulmonary resuscitation (CPR), and emergency medical services (EMS) arrival time and mortality were higher in both studies. In contrast, OHCA incidence and bystander-CPR in King County, USA remained similar to that of previous years. 4 Accordingly, we decided to investigate whether these worrying observations were present in OHCAs occurring in the Province of Padua. Of note, Padua is the most populated and densely inhabited province of Veneto Region, northeast of Italy (2142 km2, 936,274 inhabitants) and, together with Lombardy, was the first area to have an outbreak of COVID-19 outside China. Between 21st February and 30th April 2020, a total of 17,960 COVID-19 cases were reported in the Veneto region. Using retrospective data from the EMS database, we compared OHCAs occurred between 1st March and 30th April 2020 and the same period in 2019 (Table 1). During the active COVID-19 period, the EMS dispatch centre responsible for the study area had a 18% increase in daily calls (525 Æ 97 vs 446 Æ 44; P< 0.001) and a 7% increase in daily ambulances missions (240 Æ 27 vs 225 Æ 18; P< 0.001). During this period, EMS responded to a total of 200 OHCAs, consistent with the 206 OHCAs in the same period in 2019 and with characteristics of patients that did not differ substantially. We observed a numerical reduction in bystanderwitnessed cases (13/52 [25%] vs. 17/59 [29%]; P= 0.65) and bystander-CPR rate (10/55 [18%] vs. 15/60 [25%]; P= 0.38). The median time between the call and EMS arrival was 1.2 min longer in 2020 than in 2019. When we break down the total arrival time in its main components (call to dispatch, dispatch to departure, and departure to arrival), we found that the culprit interval was the time between the call and EMS departure. In particular, a delay was seen during call taking and dispatch (2.4 [1.7 À3. 1] vs 2.0 [1.6 À2. 8]; P= 0.002) and between dispatch and departure (3.9 [2.5 À6. 0] vs 3.5 [2.4 À4. 6]; P= 0.003). The increase in the call taking and dispatch process can be explained by the need to ask questions about COVID-19 status (tested positive or COVID-like symptoms), and the increased dispatchers' workload (+ 17% of calls received). Instead, the delay in ambulances departure is mainly explained by the time needed to wear personal protective equipment. Also, ambulance sanitization and the moderate increase (+ 7%) in ambulance missions might account for departures delays. Interestingly, the time between EMS departure and arrival (ie, road travel time) was significantly reduced (7.3 min [5.4 À11] vs. 8.3 min [5.7 À12]; P= 0.04), likely related to the 80% reduction in road traffic in the area5 due to lockdown (8th MarchÀ18th May 2020). Of note, resuscitation manoeuvres were less attempted by EMS (45/114 [39%] vs. 48/90 [53%]; P= 0.048) in the COVID-19 period, fear of infection might have contributed to this variation. Rates of ROSC, transport with ongoing CPR, and out-of-hospital death remained similar in the two periods.

Compared with findings from Lombardy1 and Paris, 2 we did not observe an increase in OHCA incidence and mortality, in line withwhat reported in Seattle and King County, USA. 4 Instead, a delay in EMS arrival and a numerical reduction in bystander-CPR rate was observed. Further research is needed to clarify the direct and indirect effects of COVID-19 on OHCA, with particular attention to regional variations.