Barriers to bystander CPR and AED use in out-of-hospital cardiac arrest: A narrative review.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide, with a survival to discharge rate of less than 20% in most communities. The "chain of survival" framework has served as the foundation of OHCA care for decades. This framework emphasizes early recognition, prompt bystander cardiopulmonary resuscitation (CPR), and rapid defibrillation as critical determinants of outcomes. Despite expanded CPR training initiatives and increasing automated external defibrillator (AED) use, bystander intervention remains infrequent, reflecting persistent gaps between training, device availability, and real-world action. Barriers to action include unequal access to CPR training across socioeconomic, age, and racial groups, social and gender-related hesitations, fear of harm or legal liability, and limited awareness or accessibility of AEDs. Although bystander AED use markedly improves survival to hospital discharge, it is applied in only a small fraction of public OHCA cases, emphasizing a persistent gap between effectiveness and utilization. Emerging strategies such as volunteer responder networks, GIS-guided AED placement, connected device registries, video-assisted telecommunicator CPR, and automated cardiac arrest detection are promising initiatives but require further evaluation and equitable implementation. Bridging the gap between training, access, and action through community-centered and system-level approaches is essential to improving OHCA outcomes. This narrative review synthesizes barriers to effective bystander response and examines emerging strategies to bridge the gap between training, access, and action to improve OHCA outcomes.