key: cord-0758963-72i2kvkx authors: Prezant, David J.; Lancet, Elizabeth A.; Zeig‐Owens, Rachel; Lai, Pamela H.; Appel, David; Webber, Mayris P.; Braun, James; Hall, Charles B.; Asaeda, Glenn; Kaufman, Bradley; Weiden, Michael D. title: System impacts of the COVID‐19 pandemic on New York City's emergency medical services date: 2020-11-09 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12301 sha: 06e9f69bdec999d7f8fdf3d98b278162336a5038 doc_id: 758963 cord_uid: 72i2kvkx OBJECTIVES: To describe the impact of the COVID‐19 pandemic on New York City's (NYC) 9‐1‐1 emergency medical services (EMS) system and assess the efficacy of pandemic planning to meet increased demands. METHODS: Longitudinal analysis of NYC 9‐1‐1 EMS system call volumes, call‐types, and response times during the COVID‐19 peak‐period (March 16–April 15, 2020) and post‐surge period (April 16–May 31, 2020) compared with the same 2019 periods. RESULTS: EMS system received 30,469 more calls from March 16–April 15, 2020 compared with March 16–April 15, 2019 (161,815 vs 127,962; P < 0.001). On March 30, 2020, call volume increased 60% compared with the same 2019 date. The majority were for respiratory (relative risk [RR] = 2.50; 95% confidence interval [CI] = 2.44–2.56) and cardiovascular (RR = 1.85; 95% CI = 1.82–1.89) call‐types. The proportion of high‐acuity, life‐threatening call‐types increased compared with 2019 (42.3% vs 36.4%). Planned interventions to prioritize high‐acuity calls resulted in the average response time increasing by 3 minutes compared with an 11‐minute increase for low low‐acuity calls. Post‐surge, EMS system received fewer calls compared with 2019 (154,310 vs 193,786; P < 0.001). CONCLUSIONS: COVID‐19‐associated NYC 9‐1‐1 EMS volume surge was primarily due to respiratory and cardiovascular call‐types. As the pandemic stabilized, call volume declined to below pre‐pandemic levels. Our results highlight the importance of EMS system‐wide pandemic crisis planning. During the COVID-19 pandemic, the NYC 9-1-1 EMS system experienced the largest surge it ever recorded-a surge that was more sustained and involved more critically ill patients than past catastrophic events such as the World Trade Center attacks, the 2003 blackout, and Hurricane Sandy. [6] [7] [8] [9] A series of pre-planned strategies were implemented to maintain the system's ability to function during a pandemic. These included: (1) a computer-assisted triage system to classify calls on the basis of their acuity, to dispatch response assets accordingly and to identify potential infectious disease calls so that responders could don appropriate personal protective equipment (PPE) that had been stockpiled to minimize infectious exposures and maintain workforce integrity; (2) using additional local and out-of-state ambulances to increase system capacity; and (3) addressing low-acuity call-types by telemedicine referrals that would not necessarily require an ambulance response or by a treat/release/no-transport option after ambulance response. All of the above were initiated to preserve the prioritization of 9-1-1 rapid response to high-acuity, life-threatening call-types during periods of potentially overwhelming increases in call volume demand. To understand the impact of the COVID-19 pandemic on NYC 9-1-1 EMS system, we examined 9-1-1 call volumes, call-types, and response times during the pandemic compared with the same period in 2019. We conducted a population-based, longitudinal study examining NYC Over the prior 10 years, FDNY designed and implemented multiple strategies to optimize management of disasters, including pandemics. For example, in August 2014, during the Ebola crisis, FDNY updated the NYC's 9-1-1 EMS system so that any medical call-type could include a pandemic modifying suffix (Supporting Information Table S1 ) to alert responders to take appropriate infection-control measures, including donning PPE, before patient contact. 11, 12 In February 2017, FDNY added computerized call-type triage to NYC's 9-1-1 EMS system to provide more rapid and consistent triaging of patient calls into calltypes (Supporting Information Table S1 ) based on acuity of the presenting complaint. In anticipation of COVID-19, (1) FDNY activated the "pandemic" call-type modifier ("Fever-Cough") on January 30, 2020 to alert crews that they may be responding to patients returning from CDC-identified countries of concern with suspected COVID-19 disease (flu-like or respiratory symptoms). During the pandemic, COVID-19 criteria were further expanded in a stepwise approach to broaden the identification of potential COVID-19 patients. On March 30, 2020, given increasing community infection, FDNY removed the travel requirement for any caller with COVID-19 symptoms. On April 1, all medically ill patients were classified as potential COVID-19 cases, regardless of symptoms. On April 5, a system-wide order extended PPE precautions to all patients, even trauma patients. Starting March 1, 2020, CFR firefighter responses were refocused from all high-acuity call-types to primarily cardiac arrest calls. Starting April 1, the number of 9-1-1 EMS system units were augmented by additional units supplied by local mutual aid and out-of-state ambulances through the Federal Emergency Management Agency's (FEMA) National Ambulance Contract. Starting March 31, 2020, lowacuity patients were transferred to telemedicine without an ambulance response. On April 13, 2020, patients who had an ambulance response and were found to be stable were offered a treat/release/notransport option when their COVID-19-like symptoms were minimal, their temperature did not exceed 100.4 • F, and their resting oxygen saturation was ≥95%. Three outcomes were examined in these analyses: call volumes and associated call-types, system times, and daily counts of hospital admissions and intubated patients. Calls were triaged into 65 distinct diagnostic call-types (Supporting Information Descriptive analyses of counts and means, depending on data type, were conducted for all outcomes from NYC's 9-1- The first case of COVID-19 in NYC was diagnosed on March 1, 2020. Within 2 weeks, the number of 9-1-1 EMS system calls steadily increased until mid-April ( Figure 1 ). During the pandemic peak, from During the peak-period (March 16-April 15), average response times to high-acuity calls increased by only 3 minutes, whereas average response times to low-acuity calls increased by 11 minutes (Figure 4 ). High Acuity Low Acuity April 15, 2020, average response times for low-acuity calls returned to pre-pandemic levels (10 min), a 55-min decrease in response time. Average on-scene ( Figure 3B ) and hospital turnaround ( Figure 3C) times also increased during the COVID-19 peak-period. In contrast to response times, recovery of on-scene and hospital turnaround times Daily numbers of hospitalizations and intubated patients followed patterns similar to those of the NYC 9-1-1 EMS system, peaking at 1,694 on April 6, 2020 and 2,695 on April 14, 2020, respectively ( Figure 1 ). First, as with other health crises that NYC has faced (ie, the World Trade Center attacks, H1N1, Ebola, and Hurricane Sandy), response to the surge associated with the COVID-19 pandemic required multiple simultaneous mitigation strategies. [7] [8] [9] 13, 14 Therefore, it is impossible to determine the relative contribution of any individual component of the overall strategy to maintaining the integrity of the NYC 9-1-1 EMS system. However, that does not diminish the overall impact, in that the sum of our mitigation strategies allowed the NYC 9-1-1 EMS system to remain effective by maintaining prioritization of high-acuity calls during an unprecedented health crisis. Third, we cannot determine how many patients who accepted NYC 9-1-1 EMS call transfers to telemedicine or on-scene treat/release/notransport option called the system back at a later time. A major strength of our study is the longitudinal system-wide ascertainment of NYC 9-1-1 EMS system responses in a city of 8.4 million people facing the largest pandemic since the 1918 influenza pandemic. 19 By includ-ing data from the entire NYC 9-1-1 EMS system and comparing findings to the same time period 1 year prior, the potential for ascertainment and selection biases were minimal. During the COVID-19 peak-period, sustained increases in daily EMS call volume have been reported. 20 In this description from NYC, we observed that increased 9-1-1 call volume resulted mostly from res- were also prolonged by the added time needed for ambulance decontamination. After the peak COVID-19 period, NYC 9-1-1 EMS system call volume decreased substantially to below baseline levels. Significant decreases in ED visits and hospital admissions for non-COVID-19 diagnoses occurred during the pandemic, suggesting avoidance of, or limited access to, healthcare. 2, 16, 18, [22] [23] [24] The lesson learned is that public health messaging, during and after a pandemic, must strike a careful balance between encouraging use of the 9-1-1 EMS system only for high-acuity emergencies (COVID-19-related or -unrelated) and the use of alternative resources (primary care physicians, other healthcare clinicians, telemedicine, and home monitoring) for low-acuity conditions. 25 This can occur if patients and their healthcare providers have confidence that sufficient emergency and non-emergency supplies/services exist, 26 infection controls are observed, and the costs for these services are not overwhelming. In conclusion, our study demonstrates that increased ambulance responses starting mid-March 2020 were due to respiratory and cardiovascular call-types consistent with COVID-19 infection. FDNY's pandemic planning was essential to meet the enormous, immediate, and sustained surge demands that COVID-19 placed on the largest 9-1-1 EMS system in the United States. We are deeply grateful to the out-of-hospital healthcare workers throughout NYC and this nation for their dedication and sacrifice. We acknowledge assistance in data preparation from the FDNY's Management and Planning Bureau. DJP has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. 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An open letter on COVID-19 to the American public NYC Health + Hospitals Launches At-Home COVID-19 Text Message-Based Symptom Monitoring Program The authors declare no conflicts of interest. Officer at the Office of Medical Affairs for the Fire Department of the City of New York. Additional supporting information may be found online in the Supporting Information section at the end of the article.