key: cord-0925530-0u78mbo2
authors: Uy-Evanado, Audrey; Chugh, Harpriya S.; Sargsyan, Arayik; Nakamura, Kotoka; Mariani, Ronald; Hadduck, Katy; Salvucci, Angelo; Jui, Jonathan; Chugh, Sumeet S.; Reinier, Kyndaron
title: Out-of-Hospital Cardiac Arrest Response and Outcomes During the COVID-19 Pandemic
date: 2020-08-14
journal: JACC. Clinical electrophysiology
DOI: 10.1016/j.jacep.2020.08.010
sha: 0800a5928aa37546f722996238822a4e1f0a86cf
doc_id: 925530
cord_uid: 0u78mbo2

ABSTRACT Objectives To evaluate the potential impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) response and outcomes in two US communities with relatively low infection rates. Background Studies in areas with high COVID-19 infection rates indicate that the pandemic has had direct and indirect effects on community response to OHCA and negative impacts on survival. Data from areas with lower infection rates are lacking. Methods In Multnomah County, OR and Ventura County, CA, we evaluated OHCA with attempted resuscitation by EMS from March 1 – May 31, 2020 and March 1 – May 31, 2019. Results Comparing 231 OHCA in 2019 to 278 in 2020, the proportion receiving bystander CPR was lower in 2020 (61% to 51%, p=0.02) and bystander use of automated external defibrillators (AEDs) declined (5% to 1%, p=0.02). EMS response time increased (6.6 ± 2.0 to 7.6 ± 3.0 minutes, p<0.001), and fewer OHCA survived to hospital discharge (14.7% to 7.9%, p=0.02). Incidences rates did not change significantly (p>0.07), and coronavirus infection rates were low (Multnomah 143/100,000, Ventura 127/100,000 as of May 31), compared to rates of ∼1600-3000/100,000 in the New York City region at that time. Conclusions The community response to OHCA was altered from March to May 2020, with less bystander CPR, delays in EMS response time, and reduced survival from OHCA. These results highlight the pandemic’s indirect negative impact on OHCA even in communities with relatively low incidence of COVID-19 and point to potential opportunities for countering the impact.

Out-of-hospital cardiac arrest (OHCA) results from a sudden circulatory collapse, is fatal without rapid cardiopulmonary resuscitation (CPR) and/or defibrillation, and is responsible for >350,000 deaths per year in the US. 1 Emergency Medical Services (EMS) first responders play a vital role in survival from OHCA. Rapid EMS response and high-quality CPR improve survival rates, 2, 3 and provision of bystander CPR can double survival from OHCA. 4 The novel coronavirus disease 2019 (COVID-19) pandemic, with nearly 2 million US cases and over 112,000 deaths as of June 11, 2020, 5 may directly impact cardiovascular disease burden and deaths, including OHCA, due to its effects on the heart. 6 The pandemic may also indirectly affect OHCA by altering the capacity of the community and EMS agencies to respond to OHCA. There is also evidence that patients are avoiding calling 911 or going to the hospital for chest discomfort or shortness of breath, with hospital visits for acute myocardial infarction significantly reduced during the pandemic. 7 Fear of contagion may discourage bystanders from participating in the community response to OHCA. Furthermore, EMS agencies have implemented additional screening of all 911 calls for potential COVID-19 symptoms or known infection, and new processes have been instituted for provision of personal protective equipment (PPE) to maximize safety of first responders. 8 We hypothesized that during the pandemic, community response to OHCA and EMS processes for responding to OHCA would be altered, with negative effects on survival outcomes. 

We used chi-square tests for categorical variables, and independent samples t-tests or Mann-Whitney tests for continuous variables as appropriate. Data were analyzed using SAS v9.4 (SAS Institute, Cary, NC) and 2-sided statistical tests with p<0.05 were considered significant. Threemonth incidence rates and 95% confidence intervals were calculated for each county for each year using cases from Mar 1 -May 31 in the numerator and the US Census county population estimate for July 1, 2019 in the denominator.

In the two communities during both periods in 2019 and 2020, a total of 657 potential OHCA cases were identified, 148 were excluded after adjudication, and 509 OHCA cases met inclusion criteria. During the pre-pandemic period (Mar 1 -May 31, 2019), 231 OHCA cases were included (110 in Oregon and 121 in Ventura); during the COVID-19 pandemic period (Mar 1 -May 31, 2020), 278 OHCA cases were included (126 in Oregon and 152 in Ventura). Threemonth incidence rates of OHCA in the two counties increased by 23% and 25%, respectively, from the pre-pandemic to the pandemic period: Table 2 ). An increased proportion of OHCA occurred in the home (63% vs 76%, p=0.009). OHCA cases were less likely to receive bystander CPR during the pandemic (61% vs 51%, p=0.01) (Central Illustration) and bystander use of automated J o u r n a l P r e -p r o o f external defibrillators (AEDs) declined (5% vs 1%, p=0.02). EMS response time increased from 6.5 ± 2.0 minutes to 7.6 ± 3.0 minutes during the pandemic (p<0.001), though time to defibrillation was not significantly prolonged (11.4 ± 8.4 vs 14.3 ± 9.7, p=0.08). Survival to hospital discharge was significantly lower in the pandemic period (14.7% vs 7.9%, p=0.02) (Central Illustration).

During the first three months of the COVID-19 pandemic in two communities (Multnomah County, OR and Ventura County, CA), EMS response times for OHCA were longer, bystander CPR and AED use decreased, and survival to hospital discharge for OHCA declined, compared to the same period the year prior. Incidence of OHCA also increased, but this change did not reach statistical significance.

Our findings are largely consistent with results from two studies in Europe 13, 14 and one in New York City. 15 The first, from the Lombardy region of Italy, reported a 58% increase in OHCA incidence (n=362 cases) from Feb. 20 through Mar. 31, 2020, compared to the same 40 day period in 2019 (n=229 cases), with longer EMS response times, less bystander CPR, and lower survival. 13 In Paris France, OHCA incidence doubled in the early weeks of the lockdown, the proportion admitted alive to hospital decreased from 22.8% to 12.8%. 14 The Paris study also reported longer EMS response times and declines in bystander CPR and shockable rhythm. In New York City, non-traumatic OHCA incidence with EMS resuscitation from March 1 to April 25, 2020 was 3-fold higher than the same time period a year prior, and OHCA during the pandemic had substantially lower shockable rhythm, ROSC, and survival than the year prior, though bystander CPR rates did not change. 15 These studies were conducted in areas with a higher COVID-19 incidence than in the two communities in our study; the authors estimated that individuals with suspected or diagnosed COVID-19 constituted 77% of the excess OHCA in the Italian study 13 and 33% in the Paris study. 14 In Seattle and King County, WA, with 2-3 times J o u r n a l P r e -p r o o f higher COVID-19 rates 5 than Multnomah and Ventura counties, patients with confirmed COVID-19 or COVID-like illness accounted for 5% of OHCA at home and 11% occurring in nursing homes from Feb. 26 -Apr. 15, 2020. 16 Our observation that more OHCA occurred at home during the pandemic is consistent with stay-at-home orders and may explain part of the decline in bystander CPR and AED use, though bystander response declined in all locations. The longer EMS response times and declines in bystander CPR we report have each been associated with lower survival from OHCA. 4 We observed a modest but not statistically significant increase in OHCA incidence in the two counties, despite a relatively low COVID-19 incidence (143 and 127 per 100,000 in Multnomah and Ventura counties, respectively, as of May 31, 2020 compared to ~1600 to 3000 per 100,000 in the New York City region at that time). 5 In our population, COVID-19 infection among individuals with OHCA appeared to be rare (1 OHCA case in Multnomah County was in an individual with confirmed COVID-19), in contrast to areas with higher COVID-19 incidence. 13 Additionally, we observed a higher percentage of OHCA presenting at a younger age in the pandemic period. Indirect and direct effects of the pandemic on the incidence and epidemiology of OHCA warrant further investigation over time.

Our study used a rigorous case adjudication process and included >500 OHCA from two separate communities; however, our study was limited to cases with resuscitation attempted by EMS.

Our results suggest that the pandemic may have significant effects on survival from OHCA, even in areas with relatively low COVID-19 incidence, and that optimizing community and EMS response during the ongoing pandemic and future outbreaks may improve survival.

CLINICAL COMPETENCIES This manuscript addresses clinical competencies of medical knowledge and systems-based practice regarding the impact of the ongoing COVID-19 pandemic on community and EMS response to out-of-hospital cardiac arrest (OHCA). The indirect impact of the pandemic may negatively influence survival from OHCA, with implications for clinicians caring for patients at high risk for OHCA.

TRANSLATIONAL OUTLOOK Even in geographic regions with relatively low COVID-19 incidence rates, a detrimental impact on EMS response and survival from OHCA was observed. Future research could measure the effectiveness of interventions for patients, communities, and EMS systems to improve response to and survival from OHCA during future outbreaks. J o u r n a l P r e -p r o o f .02 *For each measure, the minimum time is used (ambulance or fire). †Time to defibrillation was calculated for 62 cases in 2019 and 63 cases in 2020 with primary VF or VT; Data on arrest location was missing for 2 cases in 2019; Data on admitted alive to hospital was missing for 1 case in 2019 and 2 cases in 2020; Data on survival to hospital discharge was missing for 1 case in 2020 who was still in the hospital as of 6/15/2020.

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and venturacountycalifornia) †American Indian and Alaska Native alone, Native Hawaiian and Other Pacific Islander alone, or Two or More Races

Central Illustration. Title. Impact of the COVID-19 pandemic on EMS response time, bystander cardiopulmonary resuscitation (CPR), and survival to hospital discharge among out-of-hospital cardiac arrest (OHCA) cases. Caption: Comparing the pre-pandemic (Mar 1 -May 31, 2019) and pandemic (Mar 1 -May 31, 2020) time periods, the proportion of OHCA cases with prolonged EMS response ≥6 minutes (blue line) increased from 57% in the pre-pandemic period to 71% in the pandemic period (p=0.002). The proportion of OHCA with bystander CPR (orange line) decreased from 61% to 51% (p=0.02). Survival to hospital discharge (grey area) decreased from 14.7% to 7.9% (p=0.02). Error bars are 95% confidence intervals of proportions.