key: cord-0835889-fi2nw2ds
authors: Bharmal, Murtaza; DiGrande, Kyle; Patel, Akash; Shavelle, David M.; Bosson, Nichole
title: Impact of COVID-19 Pandemic on Cardiac Arrest and Emergency Care
date: 2022-03-29
journal: Cardiol Clin
DOI: 10.1016/j.ccl.2022.03.009
sha: b3849a95c300859887d16b18476a6a9456495acd
doc_id: 835889
cord_uid: fi2nw2ds

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the COVID-19 pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient’s behavior and health care systems contributed to these changes. Understanding potential factors offers the opportunity to improve future response and save lives.

OHCA in Paris, France and the surrounding suburbs [8] . In a meta-analysis of 10 studies with over 35,000 OHCA events in various geographic regions, Lim et al. found a 120% increase in OHCA [13] .

In contrast to the studies above, several studies found no increase in OHCA [11, [14] [15] [16] . Huber et al. found no significant increase in OHCA within a community in Germany with a low prevalence of COVID-19 infection [11] . Elmer et al. also reported no significant increase in OHCA in Pennsylvania, United States where the prevalence of COVID-19 was low [15] . Chan et al. observed communities with different COVID-19 mortality rates and found the incidence of OHCA was higher largely in communities with high COVID-19 mortality [17] . Although these studies in aggregate suggest that the incidence of OHCA is related to the prevalence of COVID-19 infection within the community, it does not follow that patients experiencing OHCA were predominately COVID-19 positive [18] .

During the COVID-19 pandemic, there were also notable changes in baseline patient characteristics among those experiencing OHCA. Lai et al. found that patients were older, less likely to be white and more likely to have comorbid conditions, including diabetes mellitus and hypertension, compared to a pre pandemic control group [12] . Non-shockable rhythms (asystole and pulseless electrical activity) were also more common. Sultanian et al. further evaluated the association between COVID-19 and the initial arrest rhythm; patients with confirmed COVID-19 were less likely to have a shockable rhythm compared to patients that were known to be COVID-19 negative [19] . While Marijon et al. did not note significant differences in baseline characteristics, the authors observed higher rates of OHCA occurring at home, less frequent bystander CPR and less frequent shockable rhythms [8] . Two Out-of-Hospital Arrest Management OHCA is a time-critical emergency, with reduced chance of survival for every minute of delay.

Multiple studies documented increased EMS response and transport times during the COVID-19 pandemic [6, 8, 18, 20, 22, 23] . Use of personal protective equipment (PPE) to ensure health care provider safety and reduce transmission of COVID-19 during on-scene resuscitation likely contributed to delays in treatment and transport [24] . Further, workforce reduction due to illness and overwhelmed healthcare systems leading to longer patient offload times at the hospital resulted in less available resources to response to time-sensitive emergencies. Changes in resuscitation protocols during the COVID-19 pandemic by various EMS systems in response to resource limitations as well as uncertainties early in the pandemic may have affected prehospital management, response and transport times [22, 25] . Early recommendations, when PPE was scarce, included limiting personal during the resuscitation, which could have had implications for outcome, and considering the appropriateness of initiation resuscitation [26] . Congruent with the observation of less frequent shockable rhythms, rates of defibrillation were significantly lower during the COVID-19 pandemic [7] . Studies also documented a reduction in attempted resuscitation measures [8] . This was again likely driven by the increase in unfavorable prognostic factors, although a fear of disease transmission by first responders, lack of EMS and hospital resources and a perception of poor prognosis for COVID positive patients experiencing OHCA may have contributed.

Outcome J o u r n a l P r e -p r o o f Studies reporting outcome events during the COVID-19 pandemic were consistent and documented lower rates of return of spontaneous circulation (ROSC), less frequent survival to hospital admission, lower survival to hospital discharge and worse neurologic outcome [8, 9, 12, 13, 20] (Table 1 ). In contrast, the most common etiology for arrest in the majority of studies during the pandemic was respiratory and the majority of patients were intubated prior to the arrest [29, 31, 35]. The majority of studies found low rates of a shockable rhythm during the COVID-19 pandemic, ranging from 3-18%, similar to pre-pandemic data [19, [29] [30] [31] [32] 36 ]. Rates of CPR within the aforementioned studies varied from 50 to 90% [29, 32] . In general, time to treatment and resuscitation times were similar during the COVID-19 period compared to prior years [31, 33] . When comparing the J o u r n a l P r e -p r o o f pandemic period to pre-pandemic event, IHCA more commonly occurred in a general medical ward (as opposed to intensive care unit) in some studies [29, 31] though other studies found higher rates of ICU IHCA during the pandemic [33] . Although location of the arrest has implications for recognition and response time, it may also reflect hospital over-crowding and conversion of non-intensive care unit beds to a semi-intensive care unit setting in some hospital systems and, therefore, would vary by region.

Early in the pandemic, there was little data to inform management. Prone positioning of patients with severe COVID-19, as well as the logistics of maintaining isolation precautions added further challenges to achieving rapid response and high-quality resuscitation. Several novel treatment approaches were suggested for IHCA during the COVID-19 pandemic, including increased use of mechanical CPR devices, performance of prone CPR and application of extracorporeal membrane oxygenation (ECMO) [37-39]. Each of these presents its own challenges and are not feasible in all health care settings. There are limited data on outcome from prone CPR; however, it has the advantage to reduce delays to initiation of compressions as well as minimizing the complications that could occur from attempting repositioning in the proned patient [38] . ECMO rapidly became a limited resource given the high burden of COVID-19 in many communities and the need for specialty centers with expertise to manage these complicated patients. As such, use of ECMO has been limited to patients with of patients is needed, especially related to the concern for increased generation of aerosolization of viral particles that places healthcare personnel at increased risk of contracting the infection.

Multiple different mechanisms have been proposed to explain how the COVID-19 pandemic may have led to the increase incidence and worse outcomes from cardiac arrest. A dichotomy that includes both the direct and indirect effects of COVID-19 is a useful framework to understand this complex The COVID-19 pandemic shifted the focus of healthcare to treatment of those afflicted with the acute respiratory infection while attempting to minimize the spread; this required changes to non-COVID medical care. Healthcare systems reorganized to accommodate the massive surge of patients with a highly infectious disease. Elective procedures including echocardiograms, cardiovascular stress tests and coronary angiography were cancelled to reallocate resources to COVID-19 treatment, as well to avoid unnecessary exposure to stable and at-risk patients. During the pandemic, hospitalization rates for congestive heart failure, acute myocardial infarction and arrhythmias were all lower than pre-COVID control periods [54] . Without timely hospitalization and/or prompt medical care, these cardiovascular conditions would be assumed to portend a higher risk for cardiac arrest ( Figure 2 ). Further, early in the pandemic, limitations in PPE and lack of rapid testing availability led to changes to emergency procedures including delaying percutaneous coronary intervention for some patients with ST segment elevation myocardial infarction [55, 56] . The psychosocial stress and reluctance to seek care in addition to the limitation of outpatient medical visits and the reduction in elective procedures are all likely contributors to the increased incidence of cardiac arrest [11, 18] .

Finally, overwhelmed healthcare systems experienced challenges in handling the demands of hospitalized COVID-19 patients, in-hospital allocation of resources and shortages in critical care services, including medical teams, equipment and intensive care unit bed availability [6] . With less available hospital resources during the pandemic, a higher threshold for hospital admission could have led to more at risk patients for cardiac arrest being discharged from emergency departments. Response times for EMS were delayed, likely related to an overwhelmed EMS response system, emergency department overcrowding and the need to use PPE during resuscitation [12, 51] . There were also higher rates for non-transport in EMS systems, leaving patients potentially at risk for clinical deterioration [57] . 

Particularly early in the pandemic, public health department messaging urged people to stay at home and lockdowns were implemented to reduce movement and potential exposure. Although a justifiable and important step to reduce the spread of infection, patients also avoided and minimized visits to outpatient clinics and to hospitals, likely due to this messaging as well as perceived risk of disease contagion. Studies published to date suggest that this resulted in worse outcome for time-J o u r n a l P r e -p r o o f sensitive cardiovascular medical conditions including cardiac arrest, ST segment elevation myocardial infarction and stroke [7] . In response, multiple public messaging campaigns have been initiated [62] .

Future messaging should continue to consider the impact on preventative and emergency care and to balance the concern for public and provider safety with the risk of delaying care for time-sensitive emergencies.

Many healthcare systems became overwhelmed with the surge of patients with acute respiratory illness and baseline preventative health and emergency services broke down. Delays to both routine and emergency care led to increased severity of illness. Healthcare systems must consider how to maintain these services while responding to a pandemic surge. Many innovative programs to optimize resources were developed in response to the pandemic and can serve as models for expansion [63] . Building up telemedicine capabilities and mobile-integrated health programs can help to maintain standard medical care when access to hospital care is limited and/or public concern leads to changes in care-seeking behavior [64] . Dispatch support systems, use of advanced providers for triage, and alternate destinations for transport can optimize deployment of EMS resources to preserve rapid response for time-sensitive emergencies. spikes in COVID-19 incidence appear to shown an increase of lesser magnitude of cardiac arrest despite an overall rise in COVID-19 infections. As healthcare systems have adapted, experience gained from the first wave may have led to better management of patients with COVID-19, allocation of resources, and evaluation of non-COVID medical issues. Efforts at mass vaccination continue and will reduce the severity of disease leading to less severe complications for those with COVID-19. The adverse impact of delaying non-COVID medical care has become readily apparent, prompting the science and medical community to widely release public campaigns to encourage patients to pursue medical care despite the ongoing pandemic. 

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