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Impact of COVID-19 Pandemic on Critical Care Transfers for ST-Segment–Elevation Myocardial Infarction, Stroke, and Aortic Emergencies

Editor


The coronavirus disease 2019 (COVID-19) pandemic has dramatically impacted healthcare delivery worldwide. In hotspot areas such as Wuhan, Lombardy, and New York City, the disease has forced hospitals to focus on patients with COVID-19. Anecdotal reports have suggested that the pandemic has led to a decrease in patients presenting to these hospitals with serious cardiovascular and neurological diseases such as ST-segment–elevation myocardial infarction (STEMI) and stroke.1,2 We sought to measure the impact of the COVID-19 pandemic on emergency transfers for STEMI, stroke, and acute aortic emergencies within our regional health system.

Methods

The Cleveland Clinic has a long-established auto-launch process that clinicians can activate to bypass the need for an accepting provider or available bed and to initiate the immediate emergency transfer for patients experiencing STEMI, acute stroke, and aortic emergencies (aortic dissection and acute abdominal aortic aneurysms).3 The Critical Care Transport System maintains a critical care transfer registry for quality management. During the COVID-19 pandemic, there has been no change in activation criteria, transport systems availability, or availability of specialty care services for these conditions. Daily emergency transfers were stratified at first baseline (January 1, 2019–March 8, 2020) and pandemic (March 9, 2020–May 6, 2020) corresponding to the declaration of the state of emergency in Ohio. The primary end point was mean daily transfer volume during the 2 time periods. Subgroup analysis was performed on STEMI, stroke, and aortic emergency transfers. A similar analysis was performed comparing a second prior year baseline (March 9, 2019–May 6, 2019) to pandemic. A statistical process control chart showed daily transfer volume trends from a third baseline (January 1, 2020–March 8, 2020) to pandemic. Poisson regression with a P<0.05 was considered statistically significant. The Cleveland Clinic Institutional Review Board approved this study. We do not plan to make the data, methods, and research materials available to other researchers.

Results

Comparing the first baseline to the pandemic, overall daily transfers fell from 4.2±2.2 to 2.5±1.5 (relative reduction: −39%, P<0.001). Subgroup analysis showed similar reductions in transfer volume for STEMI (1.1±1.1 versus 0.6±0.7, relative reduction: −48%, P<0.001), stroke (2.5±1.6 versus 1.5±1.2, relative reduction: −39%, P<0.001), and aortic emergencies (0.6±0.7 versus 0.4±0.7, relative reduction: −21%, P=0.258) although the reduction for aortic emergencies did not achieve statistical significance. Compared with the second baseline, daily transfers fell from 4.1±2.2 to 2.5±1.5 (relative reduction: −38%, P<0.001). Compared with the third baseline, daily transfer volumes fell from 4.5±2.1 versus 2.5±1.5 (relative reduction: −44%, P<0.001), with a substantial reduction in the upper confidence limits (Figure).

Figure.

Figure. Daily critical care transfer volumes between baseline and pandemic time periods in 2020. In 2020, daily transfer volumes showed a 44% reduction comparing baseline and pandemic (4.5±2.1 versus 2.5±1.5, P<0.001). Green line represents mean; and red line, upper confidence level of 3σ. STEMI indicates ST-segment–elevation myocardial infarction.

Discussion

Our analysis shows a reduction in emergency transfers for STEMI, stroke, and aortic emergencies coinciding with the COVID-19 pandemic. By using emergency transfer data, we can accurately measure the impact of the pandemic on initial disease presentation. Our study also highlights that this phenomenon is occurring in a less intensely impacted part of the world as compared to hotspots such as Wuhan, Lombardy, and New York City.

Patients may be reluctant to seek care during the pandemic because of concerns of becoming infected, violating social distancing expectations, or believing that care is not available. Prior reports have shown a decrease in STEMI in heavily impacted areas such as Spain, New York City, and Detroit.1,4 One Chinese study suggested that STEMI patients are delaying seeking medical care during the pandemic by waiting nearly 6 hours compared with 1.5 hours.5 If this is the case globally, the public health impact may be substantial. In New York City, there has been a dramatic increase in the number of patients found dead at home.6 Similarly, excess mortality has been noted in Bergamo, Italy beyond the direct mortality from COVID-19.7 Although many of these deaths may be related to COVID-19, undiagnosed emergency cardiac, neurological, and vascular conditions may also play an important role.

Our long-standing auto-launch process did not change making it unlikely that patients with these conditions would be treated differently. Also, the originating emergency departments and hospitals do not have the specialty services to take care of these emergent conditions making it very unlikely that patients would not be transferred. During the pandemic time period, utilization of hospital and ICU beds decreased substantially with occupancy levels of 60% to 70% compared with >90% prepandemic. Thus, we can exclude the lack of bed capacity as an explanation for our findings. We cannot exclude other causes of decreased transfers such as a true reduction in the incidence of these diseases due to social distancing, decreased work stressors, reduced environmental air pollution, or reduction in concomitant influenza. However, a decreased incidence of these life-threatening conditions would not align with an increase in non-COVID-19 mortality noted in New York City and Bergamo, Italy.

The COVID-19 pandemic is impacting emergency cardiac, neurological, and vascular presentations. Our findings underscore the importance of education to the public to continue to seek emergency care for serious symptoms such as chest pain and those associated with stroke during the COVID-19 pandemic.

Sources of Funding

The primary funding source was unrestricted philanthropic support to the Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Cleveland Clinic. The funding source had no role in the design or conduct of the study; collection, management, analyses, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the article for publication.

Footnotes

Umesh N. Khot, MD, Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation, Desk J2-4, 9500 Euclid Ave, Cleveland, OH 44195. Email

References



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