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Research Letters

Impact of the COVID-19 outbreak on emergency medical system missions and emergency department visits in the Venice area

Stella, Federicaa; Alexopoulos, Chiaraa,,b; Scquizzato, Tommasoa,,c; Zorzi, Alessandrod

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European Journal of Emergency Medicine: August 2020 - Volume 27 - Issue 4 - p 298-300
doi: 10.1097/MEJ.0000000000000724
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On 21 February, the first coronavirus disease 2019 (COVID-19) cases were diagnosed in Lombardy and Veneto regions of northern Italy. During the subsequent days, the number of people affected by COVID-19 increased dramatically. To face the epidemic, hospitals reorganized to increase the capacity of emergency departments (EDs), general wards and intensive care units [1]. Due to the possible overload and risk of infection, the population was warned not to misuse the emergency services [2]. In order to evaluate the results of this recommendation, we reported how the number and type of the emergency medical system (EMS) missions and admissions to the ED of a large hospital (Venice-Mestre) changed in the province of Venice, Veneto Region of Italy, after the COVID-19 outbreak started.

In the Province of Venice, a single EMS dispatch center covers an area of 2467 km2 with about 860 000 inhabitants and manages more than 95 000 emergency missions each year. The EMS of the Venice province has a single dispatch centre and is a two-tire system: in case of potentially life-threatening conditions, a medical car with an EMS physician is dispatched in addition to the ambulance. In case of chest pain (or equivalent symptoms), a 12-lead ECG is acquired on-site and sent to a cardiologist for reporting. The Venice province hospital network consists of six-spoke EDs and one hub (Venice-Mestre hospital) with 130 000 visits per year. EMS calls and ED visits were categorized according to prespecified protocols into three levels of urgency: ‘red codes’ = medical condition with acute impairment of vital signs requiring emergent care; ‘yellow codes’ = medical condition requiring urgent care with no vital signs impairment but at-risk for deterioration; ‘green code’ = less urgent or nonurgent conditions. Data are presented as counts. Behavior of counts over time has been modeled using a loess function within a Conway–Maxwell (COM)–Poisson regression allowing for time-induced overdispersion. Analyses were made with the R System X and the COMPoissonReg libraries X.

We found that the total number of EMS missions during the 6-week before and after the 21 February 2020 remained similar (from 8780, average 209/day to 8797, average 209/day). During the same periods, the total number of visits to the Venice-Mestre hospital ED reduced by 50%, from 10 949 (average 261/day, P < 0.001) to 5487 (average 131/day, P < 0.001). In 2020, the distribution of EMS missions according to severity did not significantly change before and after the COVID-19 outbreak started (Fig. 1a). Compared to the corresponding 2019 periods, in 2020 there was a similar significant reduction in ‘red’ and ‘yellow’ codes and a similar significant increase in ‘green codes’ both before and after 21 February (Fig. 1b). In 2020, overall ‘red code’ visits to the Venice-Mestre ED showed a nonsignificant 6% reduction after 21 February, while ‘yellow’ and ‘green’ code visits dropped significantly after the COVID-19 outbreak (–31 and –57%, respectively, P < 0.001) (Fig. 1c). In 2019, the cumulative number of ‘red codes’ were significantly higher compared to 2020, both before and after 21 February. On the contrary, the number of ‘yellow’ and ‘green codes’ before 21 February was similar between 2019 and 2020 while a significant reduction was observed in 2020 after this date (Fig. 1d).

Fig. 1
Fig. 1:
Trends in EMS missions and ED visits according to the color codes of urgency and in main diagnosis made by the EMS physician. EMS missions during each of the 6 weeks before (dark color bars) and after (light color bars) the COVID-19 outbreak on 21 February 2020 (a). Cumulative number of EMS missions during the 6-week periods before 21 February 2019 (B19), before 21 February 2020 (B20), after 21 February 2019 (A19) and after 21 February 2020 (A20) (b). Number of ED visits during each of the 6 weeks before (dark color bars) and after (light color bars) the COVID-19 outbreak on 21 February 2020 (c). Cumulative number of ED visits during the 6-week periods before 21 February 2019 (B19), before 21 February 2020 (B20), after 21 February 2019 (A19) and after 21 February 2020 (A20) (d). Number of medical conditions that prompted the EMS physician intervention during each of the 6 weeks before (dark color bars) and after (light color bars) the COVID-19 outbreak on 21 February 2020 (e). Cumulative number of EMS missions during the 6-week periods before 21 February 2019 (B19), before 21 February 2020 (B20), after 21 February 2019 (A19) and after 21 February 2020 (A20) (f). CARDIAC ARREST, cardiac arrests in nonterminally ill patients that prompted resuscitation attempt; CHEST PAIN other ECG+, chest pain or equivalent with significant ECG abnormalities (such as ST-segment depression) other than ST-segment elevation; CARDIAC TRAUMA, major trauma with Injury Severity Score (ISS) >15; RESP. DISTRESS, respiratory distress of cardiac or pulmonary origin; STEMI, ST-elevation myocardial infarction.

The medical conditions that prompted the dispatch of the EMS physician showed significant changes after the COVID-19 outbreak. We found a reduction in calls for chest pain without ST-segment elevation myocardial infarction (STEMI) (–54%, P = 0.024), out-of-hospital cardiac arrests (OHCA) with resuscitation efforts (–38%, P = 0.04) and major trauma (–72%, P < 0.001) and an increase in respiratory distresses (+56%, P < 0.001) (Fig. 1e). Compared to the corresponding periods in 2019, in 2020 there was a similar cumulative number of EMS missions for such conditions before 21 February but significant changes after that date. Instead, the number of missions for chest pain with STEMI was significantly lower in 2020 compared to 2019 both before and after 21 February (Fig. 1f).

In line with previous reports during the 2003 SARS epidemic, the 50% reduction in the number of ED visits following the COVID-19 outbreak may be explained by patient’s self-isolation seeking alternative treatments at home [3–7]. In contrast with such previous findings, the decrease was due not only to nonurgent visits but also to urgent/nonlife-threatening conditions such as syncope or chest pain. Furthermore, the overall number of ‘red codes’ ED admissions did not vary significantly after the COVID-19 outbreak, despite the increase in acute respiratory failures. These findings are probably explained by the fact that people were less likely to visit the ED fearing infection.

In contrast to ED visits, the number of EMS calls remained similar also after stratification for the degree of urgency, but the type of missions for life-threatening conditions associated with the dispatch of the EMS physician changed significantly. Major trauma showed the most prominent decrease, and a possible explanation is a change in the community behavior generated by the lockdown. We also observed a decrease in EMS missions due to cardiologic problems such as chest pain without ST-segment elevation on the electrocardiogram and OHCA requiring resuscitation. While it is possible that people were less likely to seek medical attention for chest pain, the decrease in OHCAs remains unexplained and warrants further investigations. At variance with our finding, in Lombardy region a 58% increase in OHCA EMS calls were observed: most of the increase was explained by patients suspected to have or who had received a diagnosis of COVID-19 [8].

Acknowledgments

We want to thank Prof. Dario Gregori (Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy) for performing the statistical analysis.

Conflicts of interest

There are no conflicts of interest.

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