key: cord-1049358-5fq4nbzz authors: Goldberg, Scott A.; Cash, Rebecca E.; Peters, Gregory; Weiner, Scott G.; Greenough, P. Gregg; Seethala, Raghu title: The impact of COVID‐19 on statewide EMS use for cardiac emergencies and stroke in Massachusetts date: 2021-01-04 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12351 sha: 1fc1a8c875ba7064ebe372dbee94ff233f2a207d doc_id: 1049358 cord_uid: 5fq4nbzz OBJECTIVE: To evaluate the impact of coronavirus disease 2019 (COVID‐19) on emergency medical services (EMS) use for time‐sensitive medical conditions. We examined EMS use for cardiac arrest, stroke, and other cardiac emergencies across Massachusetts during the peak of the COVID‐19 pandemic, evaluating their relationship to statewide COVID‐19 incidence and a statewide emergency declaration. METHODS: A retrospective analysis of all EMS calls between February 15 and May 15, 2020 and the same time period for 2019. EMS call volumes were compared before and after March 10, the date of a statewide emergency declaration. RESULTS: A total of 408,758 calls were analyzed, of which 49,405 (12.1%) represented stroke, cardiac arrest, or other cardiac emergencies. Average call volume before March 10 was similar in both years but decreased significantly after March 10, 2020 by 18.7% (P < 0.001). Compared to 2019, there were 35.6% fewer calls for cardiac emergencies after March 10, 2020 (153.6 vs 238.4 calls/day, P < 0.001) and 12.3% fewer calls for stroke (40.0 vs 45.6 calls/day, P = 0.04). Calls for cardiac arrest increased 18.2% (28.6 vs 24.2 calls/day, P < 0.001). Calls for respiratory concerns also increased (208.8 vs 199.7 calls/day, P < 0.001). There was no significant association between statewide incidence of COVID‐19 and EMS call volume. CONCLUSIONS: EMS use for certain time‐sensitive conditions decreased after a statewide emergency declaration, irrespective of actual COVID‐19 incidence, suggesting the decrease was related to perception instead of actual case counts. These findings have implications for public health messaging. Measures must be taken to clearly inform the public that immediate emergency care for time‐sensitive conditions remains imperative. Certain time-sensitive conditions including cardiac emergencies and stroke require rapid evaluation and prompt management, and EMS is often the first link in this chain of survival. Yet despite the importance of rapid medical evaluation for these time sensitive conditions, ED visits for stroke and myocardial infarction decreased suddenly and sharply after week 10 of 2020, 3 suggesting an impact of both stayat-home orders and a growing public fear of engaging the health care system. During the peak of the pandemic in Italy, acute presentations for ST elevation myocardial infarction decreased by 37% with a similar pattern seen in Madrid. 4 In addition, ED visits for low-acuity stroke decreased in Italy, with more severe strokes on presentation and patients having worse outcomes. 5 Decreased use of emergency services for time-sensitive conditions during a public health emergency suggests an impact of stay-at-home advisories and public fear of engaging the health care system and has implications for public health messaging. We performed a retrospective analysis of the Massachusetts Ambu- All 911 calls originating in Massachusetts for which patient contact was made between February 15 and May 15, 2020 were included. We also included the same time period in 2019. On March 10, 2020 the Governor of Massachusetts declared a statewide public health emergency. This time point was used to delineate "pre-COVID-19″ and "post-COVID-19″ periods for 2020. Our Chi-square tests and t tests examined associations between EMS call volumes and variables related to COVID-19 including statewide Our study has some limitations. Although Massachusetts uses a stan- Our study demonstrates a significant reduction in EMS calls for cardiac emergencies and stroke after March 10, 2020, corresponding to a statewide declaration of emergency but before any substantial increase in statewide COVID-19 incidence. Although the statewide declaration of emergency was associated with a sudden decrease in call volume, we found no correlation between statewide COVID-19 cases and overall EMS contact. The statewide rise in COVID-19 incidence that followed was not associated with corresponding reductions in EMS contact. These findings suggest that overall EMS contact was likely subject to a greater influence by the public perception of disease threat than by actual estimates of disease incidence reported over time. Both myocardial infarction and stroke are time-sensitive conditions for which rapid evaluation and management are paramount. Yet during the peak of the pandemic, ED presentations for both conditions decreased significantly not only in the United States but across the globe. [3] [4] [5] 7, 8 In both Italy and Hong Kong, emergent presentations of myocardial infarction decreased during an initial COVID-19 surge but 7 late presentations increased. 4 In addition, presentations for stroke were delayed, leading to compromised patient outcomes. 5, 9 Our study demonstrates decreased EMS contacts for potentially emergent conditions in the state of Massachusetts after March 10, 2020, suggesting that patients may have had emergent conditions for which they failed to seek timely medical care. It is possible that some of the increased number of cardiac arrests seen in our study represented late presentations of cardiac conditions, although our study was not designed to answer this specific question. There are several possible explanations for this decrease in EMS contact including decreased population mobility and fear of contracting COVID-19. During this period of uncertainty, patients seemed to avoid emergency care owing to a perception that encounters with the health care system might increase infection risk. A national survey conducted in April 2020 reported that 4 out of 5 adults were concerned about contracting COVID-19 in an ED, and 29% avoided or delayed medical care because of concern about contracting COVID-19. 10 Patient motivation is an important factor in EMS use. 11 The decline in EMS use for these conditions during our study period is concerning and has implications for public health messaging regarding the safety of receiving emergent medical care, especially considering the significant morbidity associated with delays in obtaining that care. Altruism may have also played a role as patients purposefully avoided medical care for fear of further stressing what they believed to be an overburdened health care system, despite low COVID-19 case counts and existing health care capacity. We did see a small but significant change in demographics dur- Our results demonstrate a sudden and significant decrease in EMS contact across Massachusetts for cardiac emergencies and stroke, unrelated to cumulative or daily COVID-19 case counts but temporally associated with a statewide declaration of emergency. When implementing statewide public health policy, measures should be taken to clearly inform the public that emergency care for time-sensitive conditions remains imperative. Further research is needed to determine the impact of changes in EMS contact during the COVID-19 outbreak on patient outcomes. Impact of the COVID-19 pandemic on emergency department visits -United States Effect of the Coronavirus Disease 2019 (COVID-19) pandemic on the U.S. Emergency medical services system: a preliminary report Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions -United States The obstacle course of reperfusion for ST-segment-elevation myocardial infarction in the COVID-19 pandemic Has COVID-19 played an unexpected "stroke" on the chain of survival? Utilization of emergency medical services in a large urban area: description of call types and temporal trends Impact of Coronavirus Disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China Acute stroke management pathway during Coronavirus-19 pandemic Where are all the patients? Addressing COVID-19 fear to encourage sick patients to seek emergency care. NEJM Catalyst Innovations Care Delivery Public Poll: Emergency Care Concerns Amidst COVID-19. American College of Emergency physicians Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey Clinical impression and dispatch reason categorizations for primary outcomes of cardiac emergency, cardiac arrest, and stroke Cardiac • Abdominal aortic aneurysm • Acute coronary thrombosis not resulting in myocardial infarction • Acute ischemic heart disease, unspecified • Acute pericarditis Breakdown (mechanical) of cardiac electrode, initial encounter • Breakdown (mechanical) of unspecified cardiac and vascular devices and implants • Myocardial infarction/STEMI (ST elevation myocardial infarction) unspecified • Pulmonary Embolism • Respiratory -Chest pain on breathing • Shock cardiogenic • ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial Unspecified symptoms and signs involving cognitive functions after unspecified cerebrovascular disease The authors have no conflicts of interest to report. SAG, RS, and PGG conceived the study. SAG was responsible for data collection and REC, GP, and SAG performed the statistical analysis.All authors contributed to manuscript development and revision. SAG takes responsibility for the manuscript as a whole.