Out-Of-Hospital Cardiac Arrests Seen by One System in NYC During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted the normal operations of health systems in New York City. As of May 14, 2020, there were 15,343 confirmed and 5,057 probable deaths due to COVID-19 in NYC and 186,293 confirmed cases.(1)

Emergency department (ED) respiratory volumes spiked during the first weeks of the pandemic, while overall volume decreased, according to data from the Ronald O. Perelman Department of Emergency Medicine. Emergency medical services (EMS) call volumes have been volatile, with the New York City Fire Department (FDNY) EMS system reporting record high (6,500 calls per day, up from a normal 4,000) and record low daily call volumes during the course of the pandemic.(2,3)

Due to the strain COVID-19 is placing on health systems, government and public health messaging has encouraged the public to stay home, use telemedicine, and reduce in-person healthcare visits unless they believe they truly require emergent care. The effect of this messaging on EMS call volumes and out-of-hospital cardiac arrests is unclear.(4)

Here, we describe a notable increase in out-of-hospital cardiac arrests seen by our health system-sponsored EMS service, NYU Langone Hospitals EMS, which services the NYC region. The service has 19 units; seven of them are advanced life support (ALS) units. ALS is able to intubate and administer intravenous medications. Basic life support (BLS) units can help administer certain medications and provide basic airway support.

Additionally, we report decreases in ST-elevation myocardial infraction (STEMI) and stroke activations within our hospital system. We believe these data suggest that patients who need emergency care during this pandemic are staying home, most likely due to fear of catching COVID-19.

Methods

Dispatch and run reports from our health system-sponsored EMS service from mid-March through mid-April 2020 were reviewed as part of our ongoing quality assurance processes. Given that data were obtained and used as a part of the EMS quality improvement process, the study was not human subjects research and therefore did not require IRB review. Call volumes from the same time period in 2019 and 2018 were reviewed for comparison.

For the purposes of this process, we defined out-of-hospital cardiac arrest as a patient who was pulseless on EMS arrival, became pulseless at the scene with EMS, or was transported in cardiac arrest. In-hospital stroke and STEMI activation numbers were obtained from hospital administrative records. We did not access any individual patient data for this report.

Results

Our EMS system call volume was 7,208 between March 15 and April 15, 2020, which was a slight increase from 7,173 the year before (see Table 1). During this time, crews were called to 267 patients with out-of-hospital cardiac arrest, which corresponds to 3.7 percent of the call volume, compared to 1.2 percent the year before. Of these, 228 were pronounced dead in the field and 39 were transported to the hospital. Patients were more likely to be older and more likely to be male; 92.9 percent of out-of-hospital cardiac arrests were seen in patients older than 45 years, which is a similar to the 90.1 percent in 2019 (see Table 2).

During the specified time period, the number of EMS calls involving out-of-hospital cardiac arrest within our system increased to 267, compared to 83 during the same period in 2019. In 2018, there were 75 such events. This represents a 10.7 percent increase from 2018 to 2019 and a 221.7 percent increase from 2019 to 2020 (see Figure 1).

Figure 1. Trends for out-of-hospital cardiac arrests, in-hospital STEMI activations, and in-hospital stroke diagnoses for the past three years within our system, March 15 to April 15

STEMI activations during March and April in our two primary hospitals decreased by 45 percent compared to the same period in 2019 (from 44 to 24). In 2019, they had increased more than 25 percent from 2018 (from 35 to 44). Stroke diagnoses were stable at 98 from 2018 to 2019, but decreased by 29.6 percent to 69 in 2020 (see Figure 1). Stroke activations in the field by our EMS crews increased from 17 in March and April 2019 to 29 during the same months of 2020, but this occurred in the setting of a new stroke protocol and is therefore difficult to interpret.

During the specified time period in 2020, there was no change in our system’s coverage area and none in the number of system ambulances in the field. Additional ambulances were dispatched throughout NYC by outside entities to help with record-breaking call volumes during the pandemic. If anything, these additional ambulances would have lowered the expected call volume for our own system.

Discussion

These data describe a significant increase in EMS out-of-hospital cardiac arrests during the height of the COVID-19 pandemic in NYC. The magnitude of this increase is concerning and necessitates additional investigation. While correlation does not constitute causation, it is possible that this dramatic increase is related to the COVID-19 pandemic.

The spike in out-of-hospital cardiac arrests may be directly caused by COVID-19, a disease that has proven unpredictable and often severe.(5-8) In this case, as prevalence of COVID-19 increases in the general population, an increasing number of people will die from the disease — some at home, where EMS crews will pronounce them, and some in the ED.

Patients may be avoiding healthcare facilities out of fear of contracting COVID-19.(9) Although this fear is not entirely without merit, symptoms of myocardial ischemia, stroke, or other life-threatening process warrant ED evaluation even in the setting of potential exposure to COVID-19. Increased education and more nuanced messaging may be required so that the public feels confident and safe seeking emergency care when necessary.

A more concerning explanation involves the unintended consequences of stay-at-home recommendations. Government authorities, employers, and healthcare systems have asked the public to socially distance themselves and stay at home. As medical systems, we have encouraged the public to avoid the ED unless absolutely necessary. Social distancing measures seem to be effectively flattening the curve by reducing new cases,(10) but are there other consequences to our messaging? Do patients always know when they are experiencing symptoms of a life-threatening problem? Are more people dying at home because we have asked them to stay there?

Without more robust cause-of-death data from pre-hospital arrests, it is impossible to answer these questions. The decline in emergent pathology that should not have significant month-to-month variation, like STEMI and stroke, suggests that at least some patients may be avoiding emergency care when they need it. The decline of our stroke and STEMI numbers in-hospital suggests that those with this pathology may be staying at home instead of presenting to an ED. Other authors have reported similar data for acute coronary syndrome admissions.(11)

The world has changed permanently in light of this pandemic. Every week has presented a new challenge and a new question. As a healthcare system, we must evaluate the data with a critical eye and openly discuss our strategies and outcomes. If people are staying at home with emergent diseases — such as strokes, STEMIs, and life-threatening complications from COVID-19 — we may need to reconsider how we message stay-at-home recommendations. In particular, we may need to evaluate the extent to which we ask patients to avoid presenting to emergency care. At the same time, we may need to provide routine and consistent education to the public in order to allay any fears of presenting to emergency care.

Strategies for improved communication include direct contact with patients’ primary care providers, email and text message communications with patients, and the publication of specific efforts undertaken in EDs and hospitals to mitigate the spread of the virus. In addition, further education regarding life-threatening symptoms such as chest pain or dizziness in high-risk groups or high-risk locations (assisted living facilities or nursing homes, for example) may be warranted. Campaigns to reassure patients of ED safety, along with education regarding appropriate ED use, is critical. EDs should be careful to avoid discouraging patients to seek care.

Limitations

Our study has several limitations. First, it is a retrospective review of limited data from our own system-based EMS service, limited to the past three years. Additionally, as mentioned above, the numbers we provide do not include cause-of-death data for the out-of-hospital cardiac arrests. Furthermore, data for stroke and STEMI activations describe two examples of emergent disease processes, but are not inclusive of the range of pathology seen by the ED. Lastly, three years of isolated data are descriptive of trends, but not extensive enough to perform robust statistical analysis or tests of statistical significance.

References

1. New York City Department of Health. COVID-19: Data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page . Published 2020. Accessed May 15, 2020.

2. Mosendz P. NYC’s 911 Overwhelmed with Record Number of Emergency Medical Calls. Bloomberg News. March 25, 2020. https://www.bloomberg.com/news/articles/2020-03-25/-most-since-9-11-nyc-responders-deluged-with-emergency-calls .

3. Dienst J, Winter T. NYC 911 Calls Fall to Multi-Year Low Weeks After Record High: FDNY. 2020. nbcNewYork. May 1, 2020. https://www.nbcnewyork.com/news/local/nyc-911-calls-fall-to-multi-year-low-weeks-after-record-high-fdny/2398808 .

4. Baldi E, Sechi GM, Mare C, et al. Out-of-Hospital Cardiac Arrest During the Covid-19 Outbreak in Italy. N Engl J Med. 2020:383(5):496–98.

5. Clerkin KJ, Fried JA, Raikhelkar J, et al. COVID-19 and Cardiovascular Disease. Circulation. 2020;141(20):1648–55.

6. Guo T, Fan Y, Chen M, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):1–8.

7. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020;323(20):2052–59.

8. Shao F, Xu S, Ma X, et al. In-hospital Cardiac Arrest Outcomes Among Patients with COVID-19 Pneumonia in Wuhan, China. Resuscitation. 2020;151:18–23.

9. Wong LE, Hawkins JE, Murrell KL, et al. Where Are All The Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek Emergency Care. NEJM Catalyst Innovations in Care Delivery. May 14, 2020.

10. Courtemanche C, Garuccio J, Le A, Pinkston J, Yelowitz A. Strong Social Distancing Measures in the United States Reduced the COVID-19 Growth Rate. Health Aff (Millwood). 2020:39(7). https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00608 .

11. De Filippo O, D’Ascenzo F, Angelini F, et al. Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy. N Engl J Med. 2020;383(1):88–89.vice during the COVID-19 pandemic.