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Incidence of emergency calls and out-of-hospital cardiac arrest deaths during the COVID-19 pandemic: findings from a cross-sectional study in a UK ambulance service
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  1. Karl Charlton1,
  2. Matthew Limmer1,
  3. Hayley Moore2
  1. 1 R&D Department, North East Ambulance Service NHS Trust, Newcastle Upon Tyne, UK
  2. 2 North East Ambulance Service NHS Trust, Newcastle Upon Tyne, UK
  1. Correspondence to Karl Charlton, R&D Department, North East Ambulance Service NHS Trust, Newcastle Upon Tyne NE15 8NY, UK; Karl.charlton{at}neas.nhs.uk

Abstract

Background In response to the COVID-19 pandemic, a national lockdown was introduced on 23 March 2020. In the following weeks, emergency departments in the UK reported a reduction in attendances. We aimed to explore the incidence of emergency calls across North East England, as well as the number of out-of-hospital cardiac arrest (OHCA) deaths.

Methods Data were collected for all patients who contacted North East Ambulance Service between 4 March 2019–2 June 2019 and 2 March 2020–31 May 2020 suffering stroke, ST elevation myocardial infarction, allergy, asthma, chronic obstructive pulmonary disease, falls, intoxication, seizure, sepsis, acute coronary syndrome and OHCA.

Results There were a reduction in incidence of calls, excluding OHCA, resulting in ambulance activation during the pandemic compared with same period in 2019, 16 743 versus 19 639, respectively (−14.74%). The decline in calls was partially reversed by the end of May 2020. Incidence of OHCA at the time of the national lockdown had increased by 13.79% with a peak increase of 73.56% in the second week in April 2020. OHCA deaths peaked in the first 2 weeks in April 2020, 95.65% and 90.07%, respectively, but by the end May 2020, incidence of OHCA and OHCA deaths had returned to prelockdown levels.

Conclusion Incidence of emergency calls were reduced during the pandemic compared with 2019. There was a rise in incidence of OHCA and OHCA deaths during the same period; however, these changes appear transient. Further research is required to understand patient behaviour towards seeking help during the pandemic and the long-term consequences of not doing so.

  • emergency ambulance systems
  • cardiac arrest
  • prehospital care
  • despatch
  • COVID-19

Data availability statement

Data are available on reasonable request.

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Key messages

What is already known on this subject

  • During the pandemic and the subsequent government lockdown, EDs in the UK reported a reduction in attendances.

What this study adds

  • There were fewer emergency calls to North East Ambulance Service during the pandemic compared with the same period last year. At the same time there was an increase in incidence of out-of-hospital cardiac arrest (OHCA) and OHCA deaths.

  • These changes appear to have been largely transient, and incidence of emergency calls, OHCA and OHCA deaths returned to near normal rates by the end of May 2020.

  • Ambulance services as well as the wider NHS needs to engage with the public to ensure those who require emergency care continue to seek help during the pandemic.

Background

COVID-19 required the reorganisation of UK emergency healthcare provision in order to accommodate the anticipated significant numbers of critically ill patients.1 The first reported UK fatality from COVID-19 was on 5 March 2020 and was followed by a national lockdown introduced on 23 March 2020.2 In the subsequent weeks, EDs in the UK reported a reduction in attendances.3 Ambulance services play a vital role in identifying and treating those who are critically unwell or injured. Anecdotal evidence suggested patients may have been behaving differently during the pandemic by delaying seeking help, resulting in a reduction in demand for ED and a rise in adverse outcomes, such as out-of-hospital cardiac arrest (OHCA). We aimed to explore the incidence of ambulance activation for a range of the most common emergency conditions occurring across North East England, as well as the number of OHCA deaths. We compared data during the pandemic with that during the same non-pandemic period in 2019.

Patients and methods

North East Ambulance Service (NEAS) NHS Foundation Trust is 1 of 10 ambulance services in England, serves a population of 2.71 million people4 and conveys patients to eight EDs. Anonymised data were collected for all patients who contacted NEAS between 2 March 2020 and 31 May 2020 for a range of the most common emergency conditions resulting in ambulance activation; these were stroke, ST elevation myocardial infarction (STEMI), allergy, asthma, chronic obstructive pulmonary disease (COPD), falls, intoxication, seizure, sepsis, acute coronary syndrome (ACS) and OHCA. We compared these data to that from 4 March 2019 to 2 June 2019, a non-pandemic period. Complete electronic patient care records (ePCRs) were eligible for inclusion. Repeat calls to the same incident and incomplete ePCRs were excluded; only primary diagnoses were analysed. Diagnosis of emergency conditions derived from face-to-face clinical assessment rather than telephone triage. We analysed the incidence of ambulance activation for each condition for both time periods and compared the actual and percentage difference for each week. We calculated the % weekly change of OHCA using the first week in March of each respective year as the baseline. OHCA death was measured by the number of patients declared deceased on scene. Percentages are presented correct to two decimal places.

Results

The total number of calls to NEAS for the emergency conditions that resulted in ambulance activation were reduced during the pandemic compared with the reference standard: 16 743 versus 19 639, respectively (−14.74%). We observed a decline in emergency calls from the first week in March 2020 for all emergency conditions except OHCA. At the beginning of lockdown on 23 March 2020, calls for stroke reduced by 10.10%, STEMI by 38.71%, falls by 43.09% and ACS by 26.24%. The decline in calls was partially reversed by the end of May 2020, with incidence of some emergency conditions returning to, or exceeding, 2019 levels: STEMI (−3.57%), allergy (+10%), COPD (+1.20%), falls (+41.06%) and ACS (+16.84%) (table 1).

Table 1

Incidence of emergency calls 2019 versus 2020 (n)

The incidence of OHCA was increased prior to the first COVID-19 fatality, and at the time of the national lockdown on 23 March 2020, incidence of OHCA had increased by 13.79%, with a notable surge of 73.56% in the second week in April. The number of OHCA deaths followed a similar trajectory, with an increase prior to the first COVID-19 fatality and lockdown and a peak in the first 2 weeks in April 2020, 95.65% and 90.07%, respectively. The incidence of OHCA and OHCA deaths returned to near baseline 2020 rates by the end of lockdown (table 2 and figure 1).

Table 2

Incidence of OHCA, % weekly change and weekly OHCA deaths (n)

Figure 1

Weekly incidence of OHCA 2019 v 2020.OHCA, out-of-hospital cardiac arrest.

Discussion

During the COVID-19 pandemic, there was a reduction in incidence of a range of the most common emergency conditions attended by NEAS. At the same time, there was an increase in OHCA and number of patients declared deceased on scene, with a noticeable spike in early April 2020. However, these changes appear transient, and by the end of May 2020, the incidence of emergency calls, OHCA and OHCA deaths had returned to near normal.

The reduction in emergency calls for conditions such as stroke, STEMI and ACS, and the increase in OHCA and numbers of patients who subsequently died, is notable and warrants further investigation. The reduction in incidence of ambulance activation suggests either a genuine decrease in all emergency conditions or a delay in, or reluctance to, seek help. This reduction may have been fuelled by the lockdown and explained by changes in public behaviour, the closure of many work places and the key government message to ‘stay at home’. It is not improbable that some of the additional OHCA deaths we observed occurred in patients who would have ordinarily contacted the ambulance service for help but who chose not to during the pandemic. Furthermore, the virus is known to cause respiratory or inflammatory response complications,5 acute coronary syndromes and thrombolytic emergencies,6 all of which may precipitate OHCA.

The reduction in STEMI and ACS we observed during the pandemic and return to near normal at the end of May is consistent with a national reduction in STEMI and ACS hospital admissions that occurred as early as 2 weeks prior to the first UK COVID-19 fatality.7

The increase in OHCA deaths suggests patients were not resuscitated or were unresponsive to treatment. Witnesses of OHCA may have been reluctant to provide bystander cardiopulmonary resuscitation due to increased risks of disease transmission.8 An increase in incidence of OHCA and number of patients declared deceased on scene has also been reported in France and Italy,9 10 where disease prevalence has been particularly acute.

In the event of subsequent COVID-19 lockdowns or different pandemic, ambulance services as well as the wider NHS, need to engage with the public to ensure those who require emergency care are willing to seek help. Further research is required to fully understand patient behaviour towards seeking help and the long-term consequences of not doing so.

Data availability statement

Data are available on reasonable request.

Ethics statements

Ethics approval

Favourable ethical opinion was sought and received from Wales REC 7 research ethics committee 20/WA/0135 and the health research authority.

References

Footnotes

  • Handling editor Caroline Leech

  • Twitter @charlton_karl

  • Contributors KC and ML extracted the data and wrote the manuscript. HM analysed the data and provided critical review and comment on the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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