key: cord-0710598-dbvdefrq
authors: Lerner, E. Brooke; Newgard, Craig D.; Mann, N. Clay
title: Effect of the Coronavirus Disease 2019 (COVID‐19) Pandemic on the United States Emergency Medical Services System: A Preliminary Report
date: 2020-06-17
journal: Acad Emerg Med
DOI: 10.1111/acem.14051
sha: 6421af7ecaf6e159292222d1e6ecaff6b60a09dd
doc_id: 710598
cord_uid: dbvdefrq

BACKGROUND: Our objective was to quantify trends in Emergency Medical Services (EMS) incidents as the effects of the COVID‐19 pandemic spread across the United States, and to determine if there was an increase in EMS attended deaths. METHODS: We conducted a three‐year comparative retrospective cohort analysis of data from the National EMS Information System. Data were included if care was provided between the 40(th) and 21(st) week of the next year and compared over three‐years. We included incidents identified through 9‐1‐1 where patient contact was made. The total number of EMS incidents per week was used as the denominator to calculate the rate of patient deaths and possible injury. We assessed for temporal and seasonal trends. RESULTS: Starting in the 10(th) week of 2020 there was a decrease in the number of EMS activations in the United States compared to the prior weeks and the same time period in previous years. The number of activations between week 10 and 16 decreased by 140,292 or 26.1%. The portion of EMS activations reporting a patient disposition of death nearly doubled between the 11(th) and 15(th) week of 2020 (1.49% to 2.77% of all activations). The number of EMS activations documenting a possible injury decreased from 18.43% to 15.27% between weeks 10 and 13. CONCLUSION: We found that early in the COVID‐19 outbreak there was a significant decrease in the number of EMS responses across the United States. Simultaneously the rate of EMS attended death doubled, while the rate of injuries decreased.

The effects of the Coronavirus Disease 2019 (COVID-19) pandemic on different aspects of the United States healthcare system are evolving and emerging in the literature. These effects are presumed to be directly or indirectly related to COVID-19, including massive efforts to slow the spread of the disease. Specifically, efforts were made to decrease how rapidly the virus infected the

This article is protected by copyright. All rights reserved population to avoid placing too high a burden on the healthcare system which could have resulted in an inability to meet the demand for care. This message was explained in the popular media as an effort to "flatten the curve."

As communities began to implement social distancing interventions including "stay at home" orders and messaging the concept that we had to work together to reduce the spread of the virus to decrease the burden on the healthcare system, certain social patterns began to emerge. Patient visits to Emergency departments (EDs) began dramatically trending downward. 1 The National Syndromic Surveillance Program found that from the 11 th week of 2020 (March 9 -15) to the 14 th week (March 30 -April 5) ED visits dropped from just over 2.5 million to 1.2 million. 2 Even in the region that includes New York, New Jersey, and Puerto Rico, ED visits went from 223,489 to 144,249 during that same time period. 2 Simultaneously, in New York, there were 3 deaths attributed to COVID-19 in week 11 and 3,194 in week 14, while in New Jersey the number of deaths was 2 in week 11 and 756 in week 14 (data on Puerto Rico were not available). 3 Anecdotally, emergency physicians and other emergency care providers reported fewer patient visits, but higher patient acuity in the United States. 4 These reports were supported in other countries where they too saw a drop in ED visits. [5] [6] [7] Very limited information is available on the effect of the pandemic on the emergency medical services (EMS) system. In particular, it is unknown if there has been a similar decrease in patient encounters for prehospital care providers. Anecdotal reports suggest that EMS was responding to increasing numbers of out-of-hospital cardiac arrest cases in areas hard hit by the COVID-19 outbreak. 8 This suggestion is concerning, and corroborates reports of declining ED visits, since it may be a sign of the detrimental effects of citizens with emergent conditions not seeking timely emergency care and/or possibly a direct effect of COVID-19 infection. If confirmed, such a finding could be the result of the virus going undetected in such situations, as some communities have reported that medical examiners have limited access to testing for COVID-19 in deceased patients. 9 If communities are not testing deceased patients, we may not know the full scope of the effect that the virus is having on our communities. The objective of this paper was to quantify the

This article is protected by copyright. All rights reserved trends in national EMS incidents as the effects of the pandemic spread across the United States, using absolute numbers of EMS activations, activation rates and types of EMS incidents. We also sought to determine if there was an increase in the number of EMS attended on-scene deaths, as has been reported in the popular media. 10

We conducted a three-year comparative retrospective cohort analysis of data submitted to week of 2020. These three study time periods allowed us to evaluate trends over time and to compare those trends to prior years to control for normal seasonal variation.

We analyzed all national EMS data that was available in the National EMS repository on June 3, 2020. Data were abstracted from the NEMSIS system at the NEMSIS Technical Assistance Center.

EMS responses were included if the request for aid originated through the area's emergency system Accepted Article (i.e., 9-1-1) and patient contact was documented. Patient transfers from one facility to another and non-emergent requests for private transport were excluded from the analysis.

The total number of EMS incidents per week were determined for each of the study time periods. We then used this number as the denominator to determine the rate (i.e., percentage) of specific EMS activation types per week. Documentation of patient deaths was based on a NEMSIS patient disposition variable (i.e., eDisposition.12 [Incident/Patient Disposition]) by combining patients who were identified as dead for whom resuscitation was either attempted or not and transportation was provided to a hospital or not. We included EMS responses for which a possible injury was documented as a concurrent comparison group, which is a common reason for EMS activations 11 and, hypothetically, should substantiate our approach, by demonstrating an opposite effect, due to "stay at home" orders. Potential injury incidents were identified using the NEMSIS element eSituation.02 (Possible Injury).

We analyzed data using descriptive statistics. In the National EMS repository, PCRs are provided by all EMS units responding to a request for service. Thus, if multiple units are dispatched to the same event, more than one PCR will be submitted to the National repository. We focused on

week-to-week comparisons for a defined period over several years to assess temporal and seasonal trends. Confidence bands around weekly rates are not provided, since the large number of EMS activations associated with these analyses made them nearly indistinguishable from the reported value.

The overall study time frame included 37,550,949 9-1-1 initiated EMS activations resulting in 

In this study, we found that EMS activations initiated through the emergency response system and resulting in a patient contact declined rapidly since COVID-19 cases were first identified in the United States and social distancing measures were enacted. Further, there has been an increase in the percentage of EMS attended scene deaths compared to prior weeks during similar time periods in previous years. This is in contrast to EMS activations reporting potential injuries, which decreased during the time frame representing the COVID-19 infection. These findings have both public health and economic implications for the United States emergency response system. From a public health perspective, these findings suggest that individuals are not accessing the emergency medical system with the same frequency as experienced prior to the spread of COVID-19. While some of our findings could be explained by the lifestyle changes related to stay-athome orders, such as driving less and participating in less risky recreational activities (i.e. fewer injuries), the decrease in EMS activations are likely not entirely explained by societal changes implemented in response to COVID-19. It is possible that changes in social perceptions (i.e., fear of

This article is protected by copyright. All rights reserved infection) may explain our observed increase in the frequency of scene deaths attended by EMS.

Recent publications have documented a decrease in the number of patients presenting to hospitals for acute coronary syndromes during the initial months of the pandemic in the United States, Spain, and Australia. [12] [13] [14] [15] Further, over a third of patients who delayed presenting for care of their myocardial infarction sited fear of COVID-19 or not wanting to burden the hospital as a reason for their delay. 15 This phenomenon appears to be affecting EDs and EMS systems in the United States, which could be a positive consequence if people whose medical needs don't require those services are seeking other avenues for care. However, our finding of a doubling in the rate of EMS attended deaths suggests that people who are experiencing medical emergencies are not accessing timely care. This conclusion is supported by a publication from Portugal that found an excess number of deaths that were not entirely explained by the reported fatalities due to COVID-19. 16 As well as in Italy where they too saw an increase in cardiac arrests. 17 Changes in EMS call volume and case mix can have significant negative effects on EMS providers, especially if patient needs become more significant and urgent. More severely ill patients require EMS professionals to provide more technically complex care and increased exposure to highstress situations related to patients not seeking early care for treatable conditions. These cases place additional stress and anxiety on EMS professionals, potentially resulting in long term negative consequences to the health, wellbeing, and longevity of these important front-line responders. 18

It is also important to consider the economic implications of changing EMS volumes. EMS agencies have to schedule units so that there is always additional capacity to respond to the next call. That is, if all EMS units are responding to individual patients at the same time there will be no capacity in the system for the next emergency. However, if too many units are idle then the community's cost of maintaining the EMS system becomes too high to sustain the service since many agencies only earn revenue when they treat and transport patients. Most EMS agencies are required to have a certain number of units in service in order to meet contractual obligations or due to geographic factors related to response time requirements across the service area. A drop in call volume will result in agency costs that are likely flat, while agency revenues significantly decline, Accepted Article leading to EMS budgetary shortfalls that will be difficult to recover from. The ability of EMS to quickly and efficiently respond to future emergencies could be jeopardized.

While our reported findings may adjust over time, it will be important to consider how public health messaging regarding the potential burden on healthcare systems and fears about contracting a novel virus may affect community member's decision to access care. In future outbreaks and other public health emergencies, it will be important to balance the need for people to seek and receive needed care with the requirement for communities to implement practices (such as social distancing) that are meant to address and contain an emerging threat.

This study is limited by the expansion of states participating in NEMSIS during the time frame that was studied. During the study period, the number of states contributing data to the National EMS repository NEMSIS expanded from 32 to 44. States enrolling in the National EMS repository commonly begin submitting PCRs at the beginning of the calendar year (see Figure 1 ). No states began submissions to the National EMS repository during the COVID-19 pandemic. With that expansion, the expectation is that the number of EMS activations per week would increase from

year to year. Instead, we found fewer activations from week 10 through 17 of 2020, during the period of COVID-19 community spread compared to the weeks preceding it and the same weeks in the prior time periods. Another potential limitation is that the analysis is based on EMS unit activations rather than individual patients. In some cases, multiple records may have been completed for the same patient. However, this limitation applies to all years of PCRs submitted to NEMSIS and can therefore be considered consistent across the 3 time periods. It is unknown what affect the pandemic may have had on the number of units responding to a scene. We could expect to see the practice of multiple responding units potentially decrease for responses during the pandemic to limit the number of responders and reduce exposure, as was recommended by the American Heart Association during week 15 of 2020. 19 This would result in an opposite effect than

This article is protected by copyright. All rights reserved that observed, but this assumption cannot be evaluated with the available data so there also may have been an increase in the number of units responding to each patient.

In some areas of the U.S. EMS data are submitted to the National EMS repository with a defined lag period to promote data validity. This analysis was done in the 23 rd week of 2020. It is possible that some data were not yet submitted which may affect the activation rates reported for scene deaths and patients with potential injuries. However, the use of a rate (or proportion) should minimize the impact of this potential bias. There is no obvious reason why EMS responders would systematically withhold (or accelerate) the submission of specific types of EMS activations.

We found that early in the COVID-19 outbreak there was a significant decrease in the number of EMS responses across the United States. Simultaneously the rate of EMS attended scene death doubled, while the rate of EMS activations related to patient injury decreased.

National Syndromic Surveillance Program (NSSP): Emergency Department Visits Percentage of Visits for COVID-19-Like Illness (CLI) or Influenza-like Illness (ILI)

The Untold Toll -The Pandemic's Effects on Patients without Covid-19

Non-COVID-19 visits to emergency departments during the pandemic: the impact of fear

Delayed access or provision of care in Italy resulting from fear of COVID-19

Covid-19: A&E Visits in England Fall by 25% in Week After Lockdown

html.) 10. Nearly a third of Americans have put off healthcare during COVID-19

Accepted Article This article is protected by copyright. All rights reserved 11

Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of

ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID

Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

Impact of the COVID-19 pandemic on interventional cardiology activity in Spain

Impact of COVID-19 pandemic on ST-elevation myocardial infarction in a non-COVID-19 epicenter

Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal

Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee