key: cord-0822014-f86exail authors: Siman-Tov, Maya; Strugo, Refael; Podolsky, Timna; Blushtein, Oren title: An assessment of treatment, transport, and refusal incidence in a National EMS's routine work during COVID-19 date: 2021-01-28 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2021.01.051 sha: 59613f523301d58e13783cedc85c3a21ea965a00 doc_id: 822014 cord_uid: f86exail BACKGROUND: COVID-19 created lifestyle changes, and induced a fear of contagion affecting people's decisions regarding seeking medical assistance. Concern surrounding contagion and the pandemic has been found to affect the number and type of medical emergencies to which Emergency Medical Services (EMS) have responded. AIM: To identify, categorize, and analyze Magen David Adom (MDA), Israel's national EMS, pre-hospital activities including patients' refusal to hospital transport, during the COVID-19 pandemic crises. METHODS: A comparative before and after design study of MDA incidents during March/April 2019 and March/April 2020. Medical type, frequency, demographic, location, and transport refusal proportions and outcomes were analyzed. RESULTS: A decrease of 2.6% in the total volume of incidents was observed during March and April 2020 compared with the equivalent period in 2019. This contrasted with the retrospective trend of annually increase observed through 2016–2019. Medical categories showing increase in 2020 were infectious disease, cardiac arrest, psychiatric, and labor and deliveries, with out-of-hospital deliveries increasing by 14%. Decreases in 2020 were seen in neurology and trauma, with trauma incidents occurring at home showing an 8.6% increase. Patients' refusal to transport rose from 13.4% in 2019 to 19.9% in 2020. Cases of refusals followed by death within 8 days were more prevalent in 2020. CONCLUSION: EMS must be prepared for changes in patients' behavior due to COVID concerns. Targeting populations at risk for refraining or refusing hospital transport and implementing diverse models of EMS, especially during pandemic times, will allow EMS to assist patients safely, either by reducing truly unnecessary ED visits minimizing contagion or by increasing hospital transports for patients in urgent or emergent conditions. During the current COVID-19 pandemic, Emergency Medical Service organizations globally have met the crisis while continuing their regular pre-hospital work. Routine work was influenced both by EMS workers' need to take precautions such as Personal Protective Equipment (PPE), case overload, and the risk of contagion for themselves or their patients 1 and by the patients' fear of contagion. The overwhelming realities of the pandemic did not prevent EMS from responding to out-of-hospital-cardiac-arrest (OHCA), stroke, ST Elevated Myocardial Infarction (STEMI), births, anaphylactic shock, seizures, and trauma 2,3 . However, many EMS systems, as well as other medical systems, reported changes in prevalence and types of incidents and calls 3, 4 . Lockdown and quarantine also affected locations where traumatic injuries occurred 5 . By comparing the number and type of incidents during the pandemic time to previous years, EMS and hospitals are able to assess the decline or increase in emergency incidents and characteristics. contagion has caused medical workers to fear that patients with urgent or emergent conditions will decline treatment or transport due to fear of contagion 8 . This has been shown to be a real concern, as patients with serious conditions showing obvious signs of deterioration due to neglect have admitted they delayed seeking medical attention because of fear of COVID-19 contagion in the hospital 9 . Conversely, a case study found that hospitals and primary care doctors are showing a generalized decline in alacrity treating conditions in the gray area of urgency, particularly in cardiac and cancer patients. While the decision to delay hospitalization for diagnosis or treatment, minimizing patient exposure to COVID-19, may seem compassionate and careful, this can lead to avoidable deaths 10 . In particular, changes in prevalence of urgent cases such as cardiovascular incidents, and trauma have been observed. Chicago based research reports a 20% reduction in EMS calls for suspected stroke as well as fewer hospital admissions for stroke, although the basis for the decline remains unclear 11 . Hospitals across Europe have seen a reduction in STEMI patients. Several possibilities may have contributed to this trend. Patients may be afraid of infection or neglect, EMS personnel trained to diagnose STEMI may be less available, response times and call to treatment times are significantly longer as well as added time required for Personal Protective Equipment (PPE) implementation 12 . In the USA, a preliminary analysis of STEMI during the early stages of the COVID-19 pandemic show an estimated 38% reduction in STEMI activations in hospital catheterization labs, possibly due to avoidance of medical care because of isolation and contagion fear, and increased use of pharmacological reperfusion due to COVID-19 1 . An increase in cath lab responses has been seen as well due to COVID-19 screenings and PPE requirements 13 . In Israel, as in many countries globally, the COVID pandemic heavily affected public health systems. Magen David Adom (MDA), the Israeli national EMS organization individual and mass civilian and military emergencies, and using this expertise created an overnight response to the MOH request for nationwide SARS-COV-2 sampling including home visits and drive thru centers. Moreover, during the initial COVID crisis MDA created and ran a "corona call center" responding to upwards of 50,000 calls daily. While this unprecedented COVID undertaking was occurring in MDA, ongoing routine incidents continued while showing some changes in frequency and type. This study aims to describe routine pre-hospital activities of Israel's national EMS organization during the COVID-19 pandemic crises. We believe this will enable other EMS organizations to adapt their resources and activities ensuring the ongoing health and safety of their patients. This study comparatively assessed the type, frequency, demographic, location, and refusal rate of all medical emergency incidents during the COVID outbreak in March/April 2020 with equivalent period 2019. This was a comparative before and after study using data from the MDA database derived from the Control and Command (CC) technological platform, which records, monitors, and audits all MDA activities. Our primary before and after focus was on incidents during the 2019-2020 March /April periods. Incidents were defined as emergency medical events beginning with 101 call to MDA and concluding with arrival of MDA team on site. We assessed the type and frequency of incidents in both time periods. We excluded all calls that were information-only COVID- The sum total of incidents during March/April of 2016-2020 was identified. Incidents from March/April 2019 and 2020 were categorized by medical type, and demographics (age and gender). Medical type refers to the medical assessment made by the EMS team on-scene. For various control purposes, all diagnoses in the CC system are categorized. Our study looked at the following categories: Psychiatry (including anxiety, psychotic episodes, suicide attempts), Endocrinology (including hypo/hyper glycaemia), Urology, Traumatic Injury, Ob-Gyn, Neurology (including loss of consciousness, syncope, TIA/CVA), Environmental Emergencies, Allergy and Anaphylaxis, Overdose, Burns, Cardiovascular, Respiratory, Neurological, Gastrointestinal, Infectious Disease, Cardiac Arrest, Labor and Delivery. Traumatic Injury incidents were also sub-categorized for site of occurrence due to the lifestyle changes enforced by the pandemic affecting patients' typical locations. MDA, Israel's national EMS operates on the Anglo-American model. This is the "scoop and run" response, minimizing pre-hospital time and requiring hospital transport in every case, unless met with patient refusal. The MDA team is staffed by paramedics and senior Emergency Medical Technicians (EMTs) rather than physicians. The team has no authority to decline a transport to the Emergency Department. A refusal indicates that a call was made to MDA, a medical team was dispatched, but the patient refused transport to hospital despite team's recommendation. A patient may have multiple incidents of transport refusal per study period. We also identified cases where the refusal was followed by a subsequent transport or a death. Within that category we also identified those incidents where within one hour to eight calendar days from the initial refusal, MDA was called back to the same patient, and the incident ended in transport to hospital or death. We divided all refusals into three tiers. The first category included all patients who refused transport. The second, all refusals followed by call-back leading to transport or death. The third, refusals followed by call-back with transport or death within one hour to eight days of the refusal. We also performed an analysis of the demographics of the transport refusers. and 2020). Chi square analysis and delta calculation were also applied to site of traumatic injury occurrence in cases of trauma medical codes. P value <0.05 considered statistically significant. Gender and age differences between 2019 and 2020 (March/April) in general and in refusals was analyzed by Chi square and independent sample t-test, respectively. Table 1 presents the prevalence and percent of incident types by on-scene medical category during 2019 and 2020. In 2020 we observed a significant increase in infectious diseases, cardiac arrests, psychiatric incidents, Ob-Gyn, labor and deliveries with a prehospital delivery increase of 14% (142 vs. 165 deliveries). A significant decrease was observed in neurology, cardiovascular, trauma, overdose and endocrinology (diabetes). When sub-categorizing traumatic injury by site of occurrence, a 33% decrease in workplace related trauma (p<.001) and a 44% decrease in road accident related trauma (p<.001) was observed. Traumatic injuries occurring at home showed an 8.6% increase in 2020 (p<.001) ( Table 2 ). (Figure 2) . Since the start of the coronavirus pandemic, the public has been exposed to many sources of COVID-19 information and misinformation [15] [16] [17] . The fear of contagion has led to many behavioral changes. Personal health decisions have also been affected by fear of contagion 18, 19 . Globally, EMS organizations have begun to assess the areas in which the pandemic has affected routine EMS work 1,11,12 . MDA, Israel's national EMS organization, has evaluated the differences in frequency, type, and demographic of incidents and transport refusals during March and April 2020. Our findings show that the overall volume of incidents during March and April 2020, at the height of the national lockdown, decreased compared to the parallel time in 2019. The fear of hospital contagion seems to have caused people to ignore symptoms and health concerns in favor of the seeming safety of home. Two categories, Cardiovascular and Neurology, showed a decrease in incidents. A similar finding was seen in the USA, in a preliminary analysis of STEMI during the early stages of the COVID pandemic 1 . An estimated 38% reduction in STEMI activations in hospital catheterization labs, possibly due to avoidance of medical care because of isolation and contagion fear was observed 1 . The reduction in Cardiovascular and Neurology MDA incidents may indicate that emergent situations were not reported to MDA in time due to fear of contagion, leading patients to ignore warning signs leading to increase in damage from untreated and unidentified cardiac and stroke cases. We assume that the higher rate of Cardiac Arrest codes indicates that cardiovascular events were reported only after an escalation in urgency. In the category of Traumatic Injury we observed an overall decrease in traumatic events. In Israel, when traumatic incidents were classified by site of occurrence (work, road, home) an increase was observed in trauma occurring at home, in contrast to work and road traumatic injuries where a marked decrease was observed. This correlates with the lockdown and quarantine demands, which placed people in their homes for extended periods. According to our results, certain medical category incidents increased during the COVID pandemic. The increase in psychiatric incidents, including anxiety, suicidal thoughts, psychotic episodes, corresponds to the general increase in anxiety and depression resulting from the pandemic and restrictions. Additionally, the quarantines, lockdowns and travel restrictions decreased the accessibility of support resources for patients suffering from poor emotional health 17 . Another category showing an increase in incidents was Labor and Delivery with more EMS attended out-of-hospital births, possibly reflecting patients' hesitancy to enter the hospital. The number of out-of-hospital births delivered by MDA increased by 14% in 2020. Although MDA is prepared for out of hospital births they highly recommend avoiding this medical scenario. There is scant data on COVID19 related out-of-hospital EMS delivered births. Globally, out-of-hospital births in general have fluctuating reports of neonatal and maternal morbidity and mortality. While a Finnish report did not observe neonatal mortality 24 . A longitudinal study in Slovenia 25 and a French study 26 found hospital births to be dramatically safer than out-of-hospital deliveries. Increasing awareness among the population regarding the risks of refraining from calling for EMS help or refusing transport, even during pandemics may save lives and prevent damage. By identifying the populations suited for diverse models of EMS, especially during pandemic times, ED visits may be reduced thus minimizing exposure of patients and staff. Conversely, during pandemic, team awareness and remote doctor support may reduce risky refusals for patients in urgent or emergent conditions, minimizing mortality and morbidity. The study is based on a relatively short study period, however this correlates to the period of the first wave of the pandemic when the shock of assimilating the information and misinformation as well as emotional repercussions was the greatest. In cases of death following refusals within eight days while we cannot be certain that the cause of death was the same as the cause for the initial call (as no specific medical code is given for cardiac arrest), we can assume that the close chronology of the calls indicates a connection to the initial medical code. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic Impact of the COVID-19 outbreak on emergency medical system missions and emergency department visits in the Venice area a population-based, observational study. The Lancet Public Health Epidemiology of trauma presentations to a major trauma centre in the North West of England during the COVID-19 level 4 lockdown. European journal of trauma and emergency surgery Impact of lockdown due to COVID-19 outbreak: lifestyle changes and public health concerns in India Determinants of the lifestyle changes during COVID-19 pandemic in the residents of Northern Italy. International journal of environmental research and public health EMS responses and non-transports during the COVID-19 pandemic The Untold Toll-The Pandemic's Effects on Patients without Covid-19. 11. 11. Dafer RM, Osteraas Acute Stroke Care in the Coronavirus Disease The Obstacle Course of Reperfusion for STEMI in the COVID-19 Reperfusion of STEMI in the COVID-19 Era-Business as Usual The role of emergency medical services in containing COVID-19. The American Journal of Emergency Medicine Effects of misinformation on COVID-19 individual responses and recommendations for resilience of disastrous consequences of misinformation. Progress in Disaster Science health among the general population in Italy. Frontiers in psychiatry Are we forgetting non-COVID-19-related diseases during lockdown Beyond COVID-19: a cross-sectional study in Italy exploring the Covid Collateral Impacts Evaluating the effects of COVID-19 on plastic surgery emergencies: protocols and analysis from a Level I trauma center Effect of shelter-in-place orders and the COVID-19 pandemic on orthopaedic trauma at a community level II trauma center The authors wish to thank Ms. Moran Maoz-Hartov for data mining and variable defining. All authors conceived and designed the study. OB supervised the data collection and managed the data, including quality control. MST and RS and IR provided statistical Competing Interests: None declared. The data belong to the MDA organization. Data will be made available from the corresponding author upon reasonable written request.