key: cord-0691094-sy696jyv
authors: Ota, Koshi; Nishioka, Daisuke; Katayama, Yusuke; Kitamura, Tetsuhisa; Masui, Jun; Ota, Kanna; Nitta, Masahiko; Matsuoka, Tetsuya; Takasu, Akira
title: Influence of the COVID‐19 outbreak on transportation of pregnant women in an emergency medical service system: Population‐based, ORION registry
date: 2022-02-23
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.14128
sha: 7ff57f00b580b5fe9125ecd411249c6208591b58
doc_id: 691094
cord_uid: sy696jyv

BACKGROUND: The coronavirus disease 2019 (COVID‐19), caused by Severe Acute Respiratory Syndrome Coronavirus 2, has spread rapidly across the world. OBJECTIVE: To assess the influence of the COVID‐19 pandemic on the emergency medical service (EMS) for transportation of pregnant women by ambulance. METHODS: This study was a retrospective, descriptive study using the Osaka Emergency Information Research Intelligent Operation Network system, and included pregnant women transported by ambulance in Osaka Prefecture between January 1, 2018 and December 31, 2020. The main outcome of the study was difficulty in obtaining hospital acceptance for transfer of patients (difficult‐to‐transfer cases). We calculated the rates of difficult‐to‐transfer cases using univariate and multivariate analyses. RESULTS: Of the 1 346 457 total patients transported to hospitals by ambulance in Osaka Prefecture during the study period, pregnant women accounted for 2586 (909, 943, and 734, in 2018, 2019, and 2020, respectively). Logistic regression analysis revealed that pregnant women were negatively associated with difficult‐to‐transfer cases (adjusted OR 0.36, 95% CI 0.26–0.50). Compared with 2018, 2020 was significantly associated with difficult‐to‐transfer cases (adjusted OR 1.27, 95% CI 1.24–1.30). CONCLUSION: Pregnant women were consistently associated with reduced odds for being difficult‐to‐transfer cases. The COVID‐19 pandemic might have influenced difficult‐to‐transfer cases in 2020.

community in western Japan. The ORION system was developed and introduced by the government of Osaka prefecture as an information system for managing emergency patients. It collects data via a smartphone application that is used by emergency medical service personnel for on-scene hospital selection, and accumulates data for all ambulance records. Since January 2015, diagnostic and outcome information on the patients transported to each medical institution have been merged with the ORION ambulance record data, including the smartphone application data. To assess the influence of the COVID-19 pandemic on the EMS system, we focused on pregnant women who were transported by ambulance in Osaka Prefecture ( Figure 1 ). We defined "women of childbearing age" as female patients aged 15-44 years. 11 We used the presumptive diagnosis and the final diagnosis for patients who were admitted, using the International Classification of Diseases, 10th Revision (ICD-10). 12 In the present study, we defined pregnancy-related patients (pregnancy patients) as ICD-10 codes O00-O99 and P00-P96. We also collected "COVID-19" data as ICD-10 code U07.1, and " suspected" data (if the virus not identified) as U07.2.

Patients who were not transported to a hospital were excluded from the study. The ambulance records in Osaka Prefecture are considered administrative records, and the necessity to obtain informed consent from the participants was waived because the data were anonymous. This study was approved by the Ethics Committee of Osaka Medical and Pharmaceutical University (Takatsuki City, Japan). Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were used in the design and in reporting the results of the study.

Data were uniformly collected using specific data collection forms and the reason for the ambulance call, the location of the accident, the time of day and day of the week, and the tools used, were included, in addition to age, sex, and ICD-10 code. The detailed situation and patient information were recorded in text form. These data were completed by EMS personnel and then transferred to the information center at the Osaka Municipal Fire Department (OMFD). To assure the quality of the data, incomplete data sheets were returned to the relevant EMS personnel for completion.

The primary outcome of this study was the difficulty in obtaining hospital acceptance for transfer of a patient. According to the guidelines of the Fire and Disaster Management Agency of the Ministry of Internal Affairs and Communications, we defined "difficult-totransfer cases" as those in which the time interval from arrival at the scene to departure from the scene was longer than 30 min, and those in which ambulance crews needed to make four or more phone calls to hospitals before obtaining hospital acceptance.

We calculated the numbers of patients transported by ambulance per year due to any cause except interhospital transport between Figure S1 shows violin plots of the age distribution for each patient category.

It was difficult to obtain hospital acceptance for transfer of a total of 4578 female patients of childbearing age (1500, 1503, and 1575, in 2018, 2019, and 2020, respectively, P < 0.001). For pregnant women, the total number of difficult-to-transfer cases was 36 (13, 12, and 11, in 2018, 2019 , and 2020, respectively, P = 0.919) ( Table 3 lists the results of univariate logistic regression analysis of difficult-to-transfer cases. The OR for difficult-to-transfer women of childbearing age was significantly positive in 2020 compared with 2018 and 2019, but was not significant in 2020 for pregnant women.

The OR for difficult-to-transfer cases of pregnant women was negative (adjusted OR 0.36, 95% CI 0.26-0.50) ( Table 4 ). The OR of 1.27 for 2020 was significantly positive with reference to 2018 (95% CI 1.24-1.30) in all transported patients, however the OR of 0.97 for 2020 was not significant with reference to 2018 (95% CI 0.43-2.23) in pregnant women (Table 5) . With reference to June, all the other months were positively associated with difficult-totransfer cases. In terms of time of transportation, with reference to "9 am to 10 am", all other times were positively associated with difficult-to-transfer cases. In particular, it was approximately eight times more difficult to obtain hospital acceptance for transfer during the time "2 am to 5 am" compared with '9 am to 10 am'. To investigate why it was more difficult for female patients of childbearing age to obtain hospital acceptance for transfer compared with pregnant women in the same age group (Table 4 and Table S1 ), we compared patients' vital signs during transportation between these two groups ( Figure 2 (Table S3 ). In addition, sensitivity analyses for children and elderly patients were negatively associated with difficultto-transfer cases in all transported patients, whereas adult was positively associated with difficult-to-transfer cases (Tables S4-S6 ). We did not know the exact reason why young women had greater odds of being difficult-to-transfer cases than pregnant women in the same age group. One of the reasons for this finding might be the difference in age distribution between these two categories for all years between 2018 and 2020, as shown in the violin plots in Figure S1 . Vital signs including respiratory rate, blood pressure, temperature, pulse rate, SpO 2 , and GCS were significantly different between female patients aged 15-44 and pregnant women (Figure 2 ). Another reason might be that the Obstetric and Gynecologic Cooperative System (OGCS) for pregnant women and the Neonatal Mutual Cooperative System for newborns had been established in Osaka prefecture. 13 When emergency maternal events due to obstetric diseases occur, the OGCS allows obstetricians and gynecologists to directly contact the obstetricians and gynecologists at the higher-care facility for smooth transport.

OGCS could manage for smooth transport in pregnant women effectively.

A meta-analysis of pregnant women with COVID-19 found that 76.5% of pregnant patients had mild disease, 15.9% had severe disease, and 7.7% had critical disease at the time of admission. 14 Critical disease is reported to be rare in pregnant patients but slightly increased when compared with the general population. 15 In the present study, there were no deaths of pregnant women, and univariate logistic regression analysis failed to

show any greater OR for difficult-to-transfer cases in pregnant women in 2020. This result suggests that the emergency obstetric transportation system of Osaka Prefecture (OGCS) had been 

The results of this study showed that pregnancy was consistently associated with reduced odds for difficult-to-transfer cases.

Specifically, when compared with women of childbearing age in the same age group, pregnant women had lower odds of being difficultto-transfer cases in 2020 even during the COVID-19 outbreak.

Hospitals are more likely to accept patients between 9 am and 10 am in the morning, on Fridays, and in the month of June.

The authors declare that they have no competing interests.

The datasets used in the current study are available from the corresponding author on reasonable request. 

The authors thank the EMS providers, nurses, emergency physicians and administrators for their cooperation in the ORION. We thank all the members of The Working Group to Analyze the Emergency Medical Care System in Osaka Prefecture for their kind support.

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Additional supporting information may be found in the online version of the article at the publisher's website. How to cite this article: Ota KP, Nishioka D, Katayama Y. Influence of the COVID-19 outbreak on transportation of pregnant women in an emergency medical service system: Population-based, ORION registry