Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand

Impact of COVID-19 Pandemic on Health and Life Emergencies Resulting from Illness Cases and Injuries-A Preliminary Study

Background: Despite organised efforts, the COVID-19 pandemic had a significant impact on the health status of the population and health services including the emergency medical system. The objective of the study was to investigate, based on the Emergency Medical Teams' (EMT) interventions, the impact of the COVID-19 pandemic on health and life emergencies resulting from illness cases and injuries of Polish females and males. Material and Methods: The data under analysis concern EMT interventions carried out in central and eastern Poland from 1 January 2017 to 31 December 2022 (n = 226,038). The study used descriptive statistics, the Mann-Whitney U Test, and the Chi-square test. Results: A significant increase was observed in the proportion of EMT interventions (p < 0.001) to patients with illness cases (80.30% vs. 83.17%) and a decrease in interventions to patients with injuries (19.70% vs. 16.83%) during the pandemic as compared to the pre-pandemic period. As for illness cases, the patients' ages during both periods were similar (Me = 66.00 vs. 66.00, p = 0.071). On the other hand, during the pandemic, injuries mainly affected elderly patients as compared to the pre-pandemic period (Me = 50.00 vs. 47.00, p < 0.001). The increase in the proportion of EMT interventions to patients with illness cases and the decrease in patients with injuries during the pandemic, as compared to the pre-pandemic period, concerned the area of intervention, patient's sex, and age. During the pandemic period, a significantly lower proportion of patients transported to the hospital (p < 0.001) and an increase in the proportion of patients left at the place of call (p < 0.001) were noted. Conclusions: The restrictions aimed at preventing the spread of the SARS-CoV-2 virus contributed to a reduced number of injuries without, however, reducing the number of illness cases. During the pandemic, the elderly were affected by injuries. The study indicates the need for further in-depth analyses to prepare the pre-hospital care system in Poland for the occurrence of other or similar emergencies.

What was the impact of COVID-19 restrictions on unintentional injuries, in Canada and globally? A scoping review investigating how lockdown measures impacted the global burden of unintentional injury

Background

Injuries are among the leading causes for hospitalizations and emergency department (ED) visits. COVID-19 restrictions ensured safety to Canadians, but also negatively impacted health outcomes, including increasing rates of certain injuries. These differences in trends have been reported internationally however the evidence is scattered and needs to be better understood to identify opportunities for public education and to prepare for future outbreaks.

Objective

A scoping review was conducted to synthesize evidence regarding the impact of COVID-19 restrictions on unintentional injuries in Canada, compared to other countries.

Methods

Studies investigating unintentional injuries among all ages during COVID-19 from any country, published in English between December 2019 and July 2021, were included. Intentional injuries and/or previous pandemics were excluded. Four databases were searched (MEDLINE, Embase, Web of Science, SPORTDiscus), and a gray literature search was also conducted.

Results

The search yielded 3,041 results, and 189 articles were selected for extraction. A total of 41 reports were included from the gray literature search. Final studies included research from: Europe (n = 85); North America (n = 44); Asia (n = 32); Oceania (n = 12); Africa (n = 8); South America (n = 4); and multi-country (n = 4). Most studies reported higher occurrence of injuries/trauma among males, and the average age across studies was 46 years. The following mechanisms of injury were reported on most frequently: motor vehicle collisions (MVCs; n = 134), falls (n = 104), sports/recreation (n = 65), non-motorized vehicle (n = 31), and occupational (n = 24). Injuries occurring at home (e.g., gardening, home improvement projects) increased, and injuries occurring at schools, workplaces, and public spaces decreased. Overall, decreases were observed in occupational injuries and those resulting from sport/recreation, pedestrian-related, and crush/trap incidents. Decreases were also seen in MVCs and burns, however the severity of injury from these causes increased during the pandemic period. Increases were observed in poisonings, non-motorized vehicle collisions, lacerations, drownings, trampoline injuries; and, foreign body ingestions.

Implications

Findings from this review can inform interventions and policies to identify gaps in public education, promote safety within the home, and decrease the negative impact of future stay-at-home measures on unintentional injury among Canadians and populations worldwide.

Adolescent Suicidal Behaviors During the COVID-19 Pandemic in Australia: Analysis of Acute Harms Assessed via Ambulance Data

PURPOSE

This study investigated changes in suicidal ideation, attempts, and nonsuicidal self-injury (NSSI)-related ambulance attendances among adolescents during the COVID-19 pandemic.

METHODS

An interrupted time series analysis using data from the National Ambulance Surveillance System, a globally unique mental health and suicide surveillance system. Patients aged 12-17 years from the state of Victoria, Australia who were attended by ambulance for suicide attempts, suicide ideation, and NSSI between January 2016 and October 2021 were included. Monthly ambulance attendances during the pre-COVID period (January 2016-March 2020) were compared to those in the peak period of COVID-19 (April 2020-October 2021).

RESULTS

There were 20,125 ambulance attendances for suicide ideation, suicide attempt, and NSSI in adolescents over the study period. During the pre-COVID period, the number of suicide ideation, attempts, and NSSI attendances was increasing by 1.1% per month (incidence rate ratio [IRR]:1.011; 95% confidence interval [1.009-1.013], p < .001). There was no change in the rate of all suicide ideation, attempt, and NSSI for all adolescents during the period of COVID-19. However, when disaggregated by gender, there was a 0.7% increase in the monthly rate of attendances for females (IRR: 1.007 [1.001-1.013], p = .029), and a 3.0% decrease for males (IRR: 0.970 [0.964-0.975], p < .001).

DISCUSSION

Adolescent female suicide ideation, attempt, and NSSI attendances increased during the COVID-19 period, compared with males in the same time period. These findings suggest tailored intervention strategies may be needed to address the increasing trends of self-harm among young people.

Analyzing emergency call volume, call durations, and unanswered calls during the first two waves of the COVID-19 pandemic compared to 2019: An observational study of routine data from seven bavarian dispatch centres

Background

The spread of the COVID-19 pandemic and the corresponding implementation of measures such as stay-at-home orders and curfews had a major impact on health systems, including emergency medical services. This study examined the effect of the pandemic on call volumes, duration of calls and unanswered calls to the emergency number 112.

Method

For this retrospective, descriptive study, 986,650 calls to seven emergency dispatch centres in Bavaria between January 01, 2019 and May 31, 2021 were analysed. The absolute number of calls and calls per 100,000 inhabitants as well as the number of unanswered calls are reported. The Mann‒Whitney U test was used to compare mean call durations between 2019 and 2020/2021 during several periods.

Results

Call volume declined during the pandemic, especially during periods with strict lockdown restrictions. The largest decline (-12.9 %) occurred during the first lockdown. The largest reduction in the number of emergency calls overall (-25.3 %) occurred on weekends during the second lockdown. Emergency call duration increased, with the largest increase (+13 s) occurring during the "light" lockdown. The number of unanswered calls remained at a similar level as before the pandemic.

Conclusion

This study showed that the studied Bavarian dispatch centres experienced lower call volumes and longer call durations during the first two waves of the COVID-19 pandemic (up to May 2021). Longer call durations could be the result of additional questions to identify potentially infectious patients. The fact that the number of unanswered calls hardly changed may indicate that the dispatch centres were not overwhelmed during the study period.

[Impact of the 2020 lockdown on prehospital psychiatric emergencies in a large city]

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic represented a serious challenge for healthcare systems worldwide. Special psychiatric patients represent a vulnerable group and are particularly affected by lockdown interventions. Knowledge on the possible effects for this group of patients in an emergency physician setting is low.

OBJECTIVE

The aim of this paper is to investigate the impact of the first lockdown during the COVID-19 pandemic in 2020 on emergency ambulance services for psychiatric patients in a large German city.

MATERIAL AND METHODS

A retrospective analysis was conducted on all prehospital psychiatric emergencies in a large German city during the first pandemic-related lockdown from 22 March 2020 to 4 May 2020, with the same period in 2019 serving as a reference.

RESULTS

During the first lockdown there was a significant increase in the number of emergency missions with respect to psychiatric cases. A substantial rise in substance-associated deployments was observed. Moreover, there was an increase in the proportion of psychiatric patients who did not meet emergency criteria. Suicidal tendencies and agitation status played a minor role during the lockdown.

CONCLUSION

The lockdown had a notable impact on the frequency and profile of emergency physician calls in the metropolitan area studied. The substantial increase in substance-associated callouts can be interpreted as both a deterioration in access to the healthcare system and an expression of the increased stress faced by the general population and vulnerable groups in particular.

Effect of the COVID-19 pandemic on asthma exacerbations in New Zealand: An interrupted time series analysis

Background

New Zealand (NZ) implemented some of the strictest restrictions during the novel coronavirus pandemic (coronavirus disease 2019 [COVID-19]), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). How this impacted asthma exacerbation rates in NZ is unknown.

Objective

We sought to explore the effects of the COVID-19 restrictions on asthma exacerbations in NZ during 2020.

Methods

We used a population-based, interrupted time series to examine the impact of the first COVID-19 lockdown in NZ on asthma exacerbation rate. The primary outcome measure was change in the monthly exacerbation rate, defined as hospitalization and/or course of corticosteroids, before and after the first lockdown. In a secondary analysis, we quantified the number of patients with asthma, the actual asthma exacerbation rate from March to December 2019 versus March to December 2020, and the number of asthma hospitalizations.

Results

There was a significant drop in the exacerbation rate immediately after lockdown (-3.02; P < .0001) followed by a significant and sustained increasing trend; the rate postlockdown increased relative to that prelockdown (0.27; P < .0001). Similar patterns were observed in all sociodemographic groups. In our secondary analysis, we identified 507,622 people with asthma; this reduced to 458,023 in 2020 postlockdown. The overall asthma exacerbation rate was 33.3% less in 2020 than in 2019 (reduction from 48.6/1000 patients to 32.4/1000 patients). The rate of asthma hospitalizations decreased from 9.5 per 1000 patients in 2019 to 6.2 per 1000 patients in 2020; this decrease was observed across all demographic groups.

Conclusions

The first COVID-19 lockdown in 2020 in NZ significantly reduced asthma exacerbation rates across all sociodemographic groups. Whether these reductions are sustained requires further investigation.

Pre-Hospital Emergency Medical Services Utilization Amid COVID-19 in 2020: Descriptive Study Based on Routinely Collected Dispatch Data in Bavaria, Germany

BACKGROUND AND IMPORTANCE

The COVID-19 pandemic affected the utilization of health care services and posed organizational challenges. While many previous studies focused on the misuse of pre-hospital EMS for low-urgency health problems, the pandemic has put more emphasis on the avoidance of medically necessary calls.

OBJECTIVE

To compare the utilization of pre-hospital emergency medical services before and after specific pandemic periods.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective, descriptive analysis of routine data from 26 dispatch centers in Bavaria, Germany.

OUTCOMES MEASURE AND ANALYSIS

We investigated the number of emergencies per 100,000 population, as well as the relative change in the emergency rates and transport rates in 2020, compared to the two previous years. Boxplots showed the distributions across the Bavarian districts per calendar week. The mean rates and standard deviations as well as the relative changes were presented for the specific periods. A paired samples t-test was used to compare the rates.

MAIN RESULTS

Compared to the average of the two previous years, the emergency rates in 2020 were lower in 35 out of 52 calendar weeks. The strongest reductions were observed during the first wave, where the average emergency rate declined by 12.9% (SD 6.8, p < 0.001). There was no statistically significant difference in the overall emergency rate during the summer holidays. Lower transport rates were observed throughout the year, especially during the first wave.

CONCLUSIONS

Utilization of pre-hospital emergency medical services decreased in 2020, especially during the periods with strict measures. This could be due to the lower morbidity from the behavioral changes during the pandemic, but also to the avoidance of medical services for both less urgent and severe conditions. While a reduction in unnecessary care would be beneficial, patients must be encouraged to seek necessary urgent care, even during a pandemic.

Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults

OBJECTIVES

Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index.

DESIGN

Randomized controlled trial.

SETTINGS AND PARTICIPANTS

We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI).

METHODS

We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝ_Hedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19).

RESULTS

Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝ_Hedges = -0.04 (95% CI -0.26 to 0.19) with a -0.23 mean reduction in ACB in the intervention arm and -0.19 in the control arm. Before lockdown ĝ_Hedges = -0.38 (95% CI -0.84 to 0.04) and post-lockdown ĝ_Hedges = 0.07 (95% CI -0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI -0.65 to 0.18); medium frailty (0.05; 95% CI -0.28 to 0.38); high frailty (0.08; 95% CI -0.40 to 0.56).

CONCLUSIONS AND IMPLICATIONS

The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.

Influence of epidemics and pandemics on paediatric ED use: a systematic review

OBJECTIVE

To assess the impact of epidemics and pandemics on the utilisation of paediatric emergency care services to provide health policy advice.

SETTING

Systematic review.

DESIGN

Searches were conducted of Medline, EMBASE, CINAHL, Scopus, Web of Science and the Cochrane Library for studies that reported on changes in paediatric emergency care utilisation during epidemics (as defined by the WHO).

PATIENTS

Children under 18 years.

INTERVENTIONS

National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies was used.

MAIN OUTCOME MEASURES

Changes in paediatric emergency care utilisation.

RESULTS

131 articles were included within this review, 80% of which assessed the impact of COVID-19. Studies analysing COVID-19, SARS, Middle East respiratory syndrome (MERS) and Ebola found a reduction in paediatric emergency department (PED) visits, whereas studies reporting on H1N1, chikungunya virus and Escherichia coli outbreaks found an increase in PED visits. For COVID-19, there was a reduction of 63.86% (95% CI 60.40% to 67.31%) with a range of -16.5% to -89.4%. Synthesis of results suggests that the fear of the epidemic disease, from either contracting it or its potential adverse clinical outcomes, resulted in reductions and increases in PED utilisation, respectively.

CONCLUSIONS

The scale and direction of effect of PED use depend on both the epidemic disease, the public health measures enforced and how these influence decision-making. Policy makers must be aware how fear of virus among the general public may influence their response to public health advice. There is large inequity in reporting of epidemic impact on PED use which needs to be addressed.

TRIAL REGISTRATION NUMBER

CRD42021242808.

Consumption of Antibiotics in Primary Care Setting before and during COVID-19 Pandemic in Republic of Srpska, Bosnia and Herzegovina

The pandemic of COVID-19 has brought many changes in health care systems at all levels of health care. The increase in the number of cases of COVID-19 has led to overuse and misuse of antibiotics.The aim of this study was to compare the consumption of antibiotics for systemic use in outpatients in the Republic of Srpska (RS), before and during the first year of the COVID-19 pandemic, as well as the association between antibiotic consumption and the rate of incidence and mortality of COVID-19. The total consumption of the antibiotics for systemic use (J01) in outpatients in the Republic of Srpska during 2019 was 19.40 DDD/TID, with an increase to 30.80 DDD/TID in 2020.Significantly higher use of penicillin (10.58 ± 11.01 DDD/TID in 2019 vs. 17.10 ± 13.63 DDD/TID in 2020), cephalosporins (2.68 ± 1.90 DDD/TID in 2019 vs. 5.93 ± 2.77 DDD/TID in 2020) and macrolides (2.14 ± 2.22 DDD/TID in 2019 vs. 3.40 ± 3.44 DDD/TID in 2020) was observed during the pandemic period. It is necessary to improve the prescribing practice of antibiotics at the primary health care level, public awareness about rational use of antibiotics, as well as the current antibiotic stewardship programs and control their implementation.

COVID-19 Pandemic Lockdown and Wellbeing: Experiences from Aotearoa New Zealand in 2020

In 2020, in the first COVID-19 pandemic lockdown, Aotearoa New Zealand consistently maintained stringent public health measures including stay-at-home lockdowns and distancing responses. Considering the widespread disruption to social functioning caused by the pandemic, this paper aimed to explore environmental and social factors that influenced the wellbeing of individuals during the first lockdown in Aotearoa New Zealand. Our mixed-methods study involved a survey (n = 1010) and semi-structured interviews of a subset of surveyed individuals undertaken at the tail end of the first 2020 lockdown. Survey participants were recruited through social media-driven snowball sampling, less than 50% were aged under 45 years and 85% identified as female. Of those interviewed, 63% identified as female. Qualitative interview findings and open-ended survey results were analysed thematically. Participants described a variety of factors influencing wellbeing, largely related to the community and household; physical, behavioural, and lifestyle factors; access to health services; and social and economic foundations. While much of the focus of COVID-19 recovery was on reversing the economic and physical toll of the pandemic, our findings emphasise the need to empower individuals, families, and communities to mitigate the pandemic’s negative implications on wellbeing.

Impact of COVID-19 Pandemic on Quality of Health Services Provided by Emergency Medical Services and Emergency Departments in the Opinion of Patients: Pilot Study

BACKGROUND

The aim of this study was to assess the quality of assistance provided by emergency medical service (EMS) and hospital emergency department (ED) staff in the opinion of patients.

METHODS

Simple random sampling was performed to select the responders. A group of 131 people who correctly completed the questionnaire form was included in the study. The questionnaire was directed only to patients receiving EMS and/or ED assistance during the time period when the pandemic was announced in Poland.

RESULTS

Problems in the ED were reported by 38 people (31.15%), and calling EMS was reported as generating problems by 7 people (16.67%). Dissatisfaction with the help provided in EDs was reported by 33 patients (27.05%), and dissatisfaction with the help by EMS was reported by eight people (19.05%). The assessment of the patient's satisfaction level significantly correlated with the waiting time in the ED (Spearman = 0.217; p = 0.016) as well as with the waiting for EMSs (Spearman = 0.403; p = 0.008).

CONCLUSIONS

Patients of the ambulance service and hospital emergency departments during the pandemic positively assessed the actions of medical services, despite significant delays in providing health services.

Changes in alcohol intoxication-related ambulance attendances during COVID-19: How have government announcements and policies affected ambulance call outs?

Background

In response to COVID-19, government-mandated health directives including widespread lockdowns were implemented. Changes in alcohol purchasing were reported, with growing concern that alcohol may be consumed as a way to cope with pandemic-associated stressors. Hitherto, there have been limited studies examining alcohol-related harms, including acute harms requiring an ambulance, and their relationship to government announcements or policies related to COVID-19.

Methods

Analyses were conducted between January and September 2020, with matched months in 2019, using Victorian data from the National Ambulance Surveillance System in Australia. Interrupted time series (ITS) models with odds ratios (OR) were used to map alcohol-related harms as a function of government policies for both metropolitan and regional areas.

Findings

A total of 43,003 alcohol intoxication-related ambulance attendances occurred between January 2019 and September 2020. Attendances in the home increased in 2020 by 9% compared to matched 2019 months. The most socioeconomically advantaged cases showed the highest percentage change. ITS models showed decreased odds of alcohol-related attendances at the beginning of each COVID-19 wave in metropolitan (OR:0•77; 95%CI: 0•71-0•83; p<0•001) and regional Victoria (OR: 0•72; 95%CI: 0•67-0•79, p<0•001) separately, and increased odds following the introduction of harsher restrictions in metropolitan Melbourne (OR:1•07; 95%CI:1•01-1•11, p=0•005). A 19% increase in odds of alcohol-related harms was observed at the end of the second wave lockdown period in regional Victoria (OR:1•19; 95%CI: 1•01-1•41, p=0•004).

Interpretation

Alcohol-related attendances during COVID-19 restrictions showed a displacement to home settings. Changes in patterns of harms were evident in specific sociodemographic groups, and geographic regions when mapped to government health directives. This study is one of the first to investigate alcohol-related harms at the population level in response to a global pandemic.

Funding

Commonwealth Department of Health and Victorian Department of Health.

Prehospital characteristics of COVID-19 patients in Helsinki - experience of the first wave of the pandemic

Background

There is a lack of knowledge how patients with COVID-19 disease differ from patients with similar signs or symptoms (but who will have a diagnosis other than COVID-19) in the prehospital setting. The aim of this study was to compare the characteristics of these two patient groups met by the emergency medical services.

Methods

All prehospital patients after the World Health Organisation (WHO) pandemic declaration 11.3.2020 until 30.6.2020 were recruited for the study. The patients were screened using modified WHO criteria for suspected COVID-19. Data from the electronic prehospital patient reporting system were linked with hospital laboratory results to check the laboratory confirmation for COVID-19. For comparison, we divided the patients into two groups: screening- and laboratory-positive patients with a hospital diagnosis of COVID-19 and screening-positive but laboratory-negative patients who eventually received a different diagnosis in hospital.

Results

A total of 4157 prehospital patients fulfilled the criteria for suspected COVID-19 infection during the study period. Five-hundred-thirty-six (12.9%) of the suspected cases received a laboratory confirmation for COVID-19. The proportion of positive cases in relation to suspected ones peaked during the first 2 weeks after the declaration of the pandemic. In the comparison of laboratory-positive and laboratory-negative cases, there were clinically insignificant differences between the groups in age, tympanic temperature, systolic blood pressure, heart rate, on-scene time, urgency category of the call and mode of transportation. Foreign-language-speakers were overrepresented amongst the positive cases over native language speakers (26,6% vs. 7,4%, p < 0,001). The number of cases in which no signs or symptoms of COVID-19 disease were reported, but patients turned out to have a positive test result was 125 (0,3% of the whole EMS patient population and 11,9% of all verified COVID-19 patients encountered by the EMS).

Conclusions

In a sample of suspected COVID-19 patients, the laboratory-positive and laboratory-negative patients were clinically indistinguishable from each other during the prehospital assessment. Foreign-language-speakers had a high likelihood of having Covid-19. The modified WHO criteria still form the basis of screening of suspected COVID-19 patients in the prehospital setting.