Emergency Medical Services Prehospital Response to the COVID-19 Pandemic in the US: A Brief Literature Review

Abstract

This study aimed to analyze prehospital Emergency Medical Services (EMS) response to the COVID-19 pandemic in the US through a brief systematic review of available literature in context with international prehospital counterparts. An exploration of the NCBI repository was performed using a search string of relevant keywords which returned n=5128 results; articles that met the inclusion criteria (n=77) were reviewed and analyzed in accordance with PRISMA and PROSPERO recommendations. Methodical quality was assessed using critical appraisal tools, and the Egger’s test was used for risk of bias reduction upon linear regression analysis of a funnel plot. Sources of heterogeneity as defined by P < 0.10 or I^2 > 50% were interrogated. Findings were considered within ten domains: structural/systemic; clinical outcomes; clinical assessment; treatment; special populations; dispatch/activation; education; mental health; perspectives/experiences; and transport. Findings suggest, EMS clinicians have likely made significant and unmeasured contributions to care during the pandemic via nontraditional roles, ie, COVID-19 testing and vaccine deployment. EMS plays a critical role in counteracting the COVID-19 pandemic in addition to the worsening opioid epidemic, both of which disproportionately impact patients of color. As such, being uniquely influential on clinical outcomes, these providers may benefit from standardized education on care and access disparities such as racial identity. Access to distance learning continuing education opportunities may increase rates of provider recertification. Additionally, there is a high prevalence of vaccine hesitancy among surveyed nationally registered EMS providers. Continued rigorous investigation on the impact of COVID-19 on EMS systems and personnel is warranted to ensure informed preparation for future pandemic and infectious disease responses.

Full text

REVIEW
Emergency Medical Services Prehospital Response
to the COVID-19 Pandemic in the US: A Brief
Literature Review
Christian Angelo I Ventura
1–3
, Edward E Denton
3–5
, Jessica Anastacia David
6
,
Brianna J Schoenfelder
7
, Lillian Mela
8
, Rebecca P Lumia
9
, Rachel B Rudi
3
, Barnita Haldar
3,10
1
Department of Graduate Medical Sciences, Boston University School of Medicine Boston, Boston, MA, USA;
2
Department of Health, Behavior and
Society (Incoming), Johns Hopkins Bloomberg School of Public Health Baltimore, Baltimore, MD, USA;
3
EMS Pandemic Response Research Laboratory
Lawrenceville, Lawrenceville, NJ, USA;
4
Department of Emergency Medicine, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR,
USA;
5
Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA;
6
Department of
Biochemistry and Microbiology, Rutgers University New Brunswick, Brunswick, NJ, USA;
7
Department of Neuroscience, Temple University
Philadelphia, Philadelphia, PA, USA;
8
Department of Nursing, Simmons University Boston, Boston, MA, USA;
9
Department of Biology, Northeastern
University Boston, Boston, MA, USA;
10
Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham School of
Medicine Birmingham, Birmingham, AL, USA
Correspondence: Christian Angelo I Ventura, Tel +1 (732) 372-2141, Email venturachri@gmail.com; cventura@bu.edu
Abstract: This study aimed to analyze prehospital Emergency Medical Services (EMS) response to the COVID-19 pandemic in the US
through a brief systematic review of available literature in context with international prehospital counterparts. An exploration of the NCBI
repository was performed using a search string of relevant keywords which returned n=5128 results; articles that met the inclusion criteria
(n=77) were reviewed and analyzed in accordance with PRISMA and PROSPERO recommendations. Methodical quality was assessed using
critical appraisal tools, and the Egger’s test was used for risk of bias reduction upon linear regression analysis of a funnel plot. Sources of
heterogeneity as dened by P < 0.10 or I^2 > 50% were interrogated. Findings were considered within ten domains: structural/systemic; clinical
outcomes; clinical assessment; treatment; special populations; dispatch/activation; education; mental health; perspectives/experiences; and
transport. Findings suggest, EMS clinicians have likely made signicant and unmeasured contributions to care during the pandemic via
nontraditional roles, ie, COVID-19 testing and vaccine deployment. EMS plays a critical role in counteracting the COVID-19 pandemic in
addition to the worsening opioid epidemic, both of which disproportionately impact patients of color. As such, being uniquely inuential on
clinical outcomes, these providers may benet from standardized education on care and access disparities such as racial identity. Access to
distance learning continuing education opportunities may increase rates of provider recertication. Additionally, there is a high prevalence of
vaccine hesitancy among surveyed nationally registered EMS providers. Continued rigorous investigation on the impact of COVID-19 on EMS
systems and personnel is warranted to ensure informed preparation for future pandemic and infectious disease responses.
Keywords: EMS, COVID-19, prehospital, pandemic response, EMT, paramedic
Introduction
Prehospital clinical care under the purview of Emergency Medical Services (EMS) has been traditionally understudied in
the United States, as illustrated by the scarcity of literature as compared to other allied health professions. Under the
federal oversight of the National Highway Trafc Safety Administration (NHTSA), EMS models of care vary drastically,
shaped largely by geographic assignment, local community partners, and additional presiding authorities. Common
models include municipality-based, private nonprot, and private for-prot services.
1
Within these structural differences exist a subset variance of agencies’ scope of practice. In accordance with the
National EMS Scope of Practice Model, the Basic Life Support (BLS) scope extends to Emergency Medical Responders
(EMRs) and Emergency Medical Technicians (EMTs), while the Advanced Life Support (ALS) scope is characteristic of
Advanced EMTs (AEMTs) and Paramedics (EMT-Ps).
2
As of January 2022, COVID-19, the respiratory infection caused
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Open Access Emergency Medicine Dovepress
open access to scientific and medical research
Open Access Full Text Article
Received: 11 March 2022
Accepted: 23 May 2022
Published: 30 May 2022

by novel SARS-CoV-2, is a leading cause of death in the US.
3
This global pandemic has established an unprecedented
call for rigorous investigation of resource capacity and competency amid allied health care industries to ascertain
structural decits and strengths that have implications for future pandemic response. Further, preliminary mixed-method
studies on EMS pandemic response in the context of the COVID-19 pandemic have identied decits in the domains of
resource availability, continued education, administrative protocols, and decontamination practices.
4
Although evidently there is an apparent scarcity of academic literature centering US EMS systems in response to the
COVID-19 pandemic, it may be useful to summatively review existing literature of satisfactory methodical quality to
highlight research areas that warrant further investigatory attention, as no review of this scope and nature currently exists.
In this study, we aimed to systematically review peer-reviewed literature indexed in PubMed pertaining to COVID-19
considerations, effects, and implications on US EMS systems and clinicians within the context of prehospital interna-
tional counterparts by employing articial intelligence and conventional PRISMA and PROSPERO recommendations.
Methods
Search Strategy
On 07 March 2022 a PubMed National Center for Biotechnology Information (NCBI) repository search was conducted
using the keywords “COVID,” “COVID-19,” “SARS-COV-2,” “CORONAVIRUS,” “EMERGENCY MEDICAL
SERVICES,” “EMS”, “EMT”, “PREHOSPITAL,” “OUT OF HOSPITAL,” and “PARAMEDIC.” The returned English
results were uploaded to Rayyan.ai for comprehensive abstract and full text review.
5
Data Extraction
Duplicate results were assessed for and removed. Editorials, commentaries, and non-peer reviewed manuscripts were excluded.
Two investigators independently reviewed abstracts to identify articles eligible for full text review. The investigators then
independently reviewed full text articles to identify studies that met the PICOS-guided inclusion criteria.
6
Studies were excluded
if there were concerns regarding methodical quality or integrity of the data as per discretion of the two investigators and a third
consultant. SIGN appraisal tools were used to exclude retrospective and cohort-based studies that did not meet an acceptable
level of evidence for inclusion in the review.
7
Conicts were resolved through discussion and by mediation from a third or fourth
consultant when necessary. Study methods were consistent with PRISMA recommendations, and although PROSPERO
registration was not sought, the work remained faithful to conventional review standards.
8,9
Analysis
Stata/BE software was used to assess aggregate prevalence of data. Heterogeneity was dened as P < 0.10 or I^2 > 50%
which warranted a xed effects approach.
10
Otherwise, a random effects approach was assumed. We then sought to
investigate sources of heterogeneity. During full text review, studies were primarily taxonomized in one of the following
ten domains: i. structural/systemic, ii. clinical outcomes, iii. clinical assessment, iv. treatment, v. special populations, vi.
dispatch/activation, vii. education, viii. mental health, ix. perspectives/experiences, x. transport.
Methodical Quality
Investigators determined risk of bias for prevalence studies based upon appropriateness of sampling, sampling methods, use of
standard assessment methods, and setting characteristics. The criteria were adapted from either the Joanna Briggs Institute
Critical Appraisal Checklist for Studies Reporting Prevalence Data or the Joanna Briggs Institute Critical Appraisal Tool for
Quasi-Experimental Studies.
11,12
A 95% condence interval was used to standardize prevalence and pooling of data, and the
linear regression based Egger’s test was used to analyze the presence of any publication bias after a funnel plot was created and
assessed.
13
P > 0.05 deemed no risk of publication bias. Microsoft Excel was used to calculate standard deviation and mean.
Sensitivity analyses assessed for source of heterogeneity and stability of results. Because the work did not involve the use of
human research subjects, it did not require approval or review by an institutional review board or bioethics committee.
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Diversity in the Research Team
The work represents a cross-institutional and multi-disciplinary collaboration amongst public health oriented researchers,
EMS clinicians, and physician scientists.
Results
The NCBI repository returned n=5128 results, with n=77 utilized for analysis and inclusion in this study. Results were
excluded if they did not satisfy the inclusion criteria. Figure 1 depicts an overview of the exclusion schema. AI identied
n=111 duplicative results, n=4916 results were excluded due to irrelevance with respect to the area of investigation, and
n=24 studies were excluded after investigators performed full text reviews and found studies to be of unsatisfactory
evidence levels in accordance with SIGN appraisal guidelines. Table 1 depicts characteristics of studies selected for
inclusion, with high condence in stability and quality of the aggregate data.
Of the included studies, 44% were US-based. Primary taxonomy schema revealed the following prevalence of data:
n=16 structural/systemic, n=23 clinical outcomes, n=7 clinical assessment, n=4 treatment, n=3 special populations, n=2
dispatch/activation, n=6 education, n=3 mental health, n=6 perspectives/experiences, and n=7 transport (see Table 1).
Figure 1 Schematic selection of relevant articles for inclusion in review.
Table 1 Characteristics of Studies Selected for Inclusion
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
1 Slavova et.
al
14
Signal of increased
opioid overdose
during COVID-19
from emergency
medical services
data
Cohort Incidences of
opioid overdose
Kentucky, US ●Post-COVID emergency declaration, daily opioid
overdose runs increased.
●EMS conditions for other chief complaints remained
static or declined.
●50% increase in suspected opioid overdose death
calls.
Clinical
Outcomes
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
2 Tien et. al
15
Critical care
transport in the
time of COVID-19
Case Performance of
region-based
medical transport
service
Ontario, CA ●Ornge, a critical care transport service, has
transported 325 patients either conrmed or
suspected to have COVID-19.
●This was divided into three types of transport:
critical care land ambulances (52.3%), PC-12 Next
Generation xed wing aircraft (28.9%), and AW-139
rotary wing aircraft (16.6%).
●No staff members tested positive for COVID-19
during this period.
●Though not typical for critical care transport, Ornge
has also transported 450 COVID-19 test samples.
Transport
3 Dahmen et.
al
16
COVID-19 Stress
test for ensuring
emergency
healthcare: strategy
and response of
emergency medical
services in Berlin
Case Emergency calls
by region-based
medical transport
service
Berlin, DE ●Increase in visits to patients with acute respiratory
diseases.
●11% of all visits were to patients suspected of having
COVID-19.
●The average call time increased by 1 minute and 36
seconds due to extended screening processes.
●The average visit time increased by 17 minutes when
patients experienced acute respiratory problems.
Structural/
Systemic
4 Levy et. al
17
Correlation
between Emergency
Medical Services
Suspected COVID-
19 Patients and
Daily
Hospitalizations
Retrospective,
correlational
Statewide EMS
electronic
medical records
Maryland, US ●26,855 patients out of 225,355 emergency calls were
considered to be suspected COVID-19 cases.
●91.2% of these patients were moved to hospitals and
25.6% had abnormal initial pulse oximetry.
●Cross correlation was found between transports and
daily hospitalizations, with a 9-day lag in
hospitalization rate (p < 0.01).
Clinical
Outcomes
5 Şan et. al
18
Effects of COVID-
19 Pandemic on
Emergency Medical
Services
Retrospective,
correlational
Provincial EMS
electronic
medical records
Ankara, TR ●90.9% increase in calls during the COVID-19
pandemic.
●Of these, 15.2% were suspected to have COVID-19
and 2.9% were eventually diagnosed.
●Frequency of cases for children 0–18 decreased,
while 18+ saw an increase.
●Symptoms of fever and cough increased by 14.1% and
956.3%, respectively.
●Other cases such as myocardial infarction or
cerebrovascular disease decreased in frequency.
Structural/
Systemic
6 Handberry
et. al
19
Changes in
Emergency Medical
Services Before and
During the COVID-
19 Pandemic in the
United States,
January 2018-
December 2020
Longitudinal Nationwide 911
activations from
NEMSIS data
US ●Decrease in overall volume of EMS cases during the
early pandemic.
●However, there was an increase in on-scene death
(1.3% to 2.4%), cardiac arrest (1.3% to 2.2%), and
opioid use or overdose (0.6% to 1.1%) during the
early height of the pandemic.
Structural/
Systemic
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
7 Roto-
Cámara et.
al
20
Psychological
Impact of the
COVID-19
Pandemic on Out-
of-Hospital Health
Professionals: A
Living Systematic
Review
Systematic
Review
Peer-reviewed
literature
Global ●6.8% of participants examined experience post
traumatic stress, between 15–20% experience
anxiety, and around 15% have a history of depression.
●Female out-of-hospital health professionals, and
those who worked closely with COVID-19 patients
were more likely to have stress or anxiety during this
time.
●Health professionals with history of illnesses that
could make them more susceptible to infection were
more likely to have depressive symptoms.
Mental
Health
8 Al Amiry,
Maguire
21
Emergency Medical
Services (EMS) Calls
During COVID-19:
Early Lessons
Learned for
Systems Planning (A
Narrative Review)
Narrative
Review
Peer-reviewed
literature
Global ●Call volume and response time dramatically
increased, most notably Israel with a 1900% increase
in calls and India with an up to 12 hour response
time.
●Length of call time increased, eg from 8 minutes to 1
hour in Italy.
●Fewer calls were made for cases of stroke and
cardiac arrest, which lead to collateral mortality (eg
300% increase in mortality in Italy one month post-
pandemic).
Dispatch/
Activation
9 Satty et. al
22
EMS responses and
non-transports
during the COVID-
19 pandemic
Case Control 911 call
responses by 22
regiospecic EMS
agencies
Pennsylvania,
US
●26.5% decrease in EMS response in 2020, compared
to responses per year from 2016–2019.
●Slight increase in respiratory illnesses and patients’
abnormal vital signs.
●48% increase in non-transports in April 2020
compared to April 2019.
Transport
10 Grawey et.
al
23
ED EMS time: A
COVID-friendly
alternative to
ambulance ride-
alongs
Qualitative Medical students Wisconsin, US ●ED-EMS time is an effective alternative to EMS ride
time.
●Medical students report increased understanding of
EMS capabilities and prehospital considerations.
●Method limits patient contact, maintains PPE, and
limits COVID-19 exposure.
Education
11 Fernandez
et. al
24
COVID-19
Preliminary Case
Series:
Characteristics of
EMS Encounters
with Linked
Hospital Diagnoses
Cohort National EMS
electronic
medical records
US ●EMS COVID-19 Suspicion was present in 78% of
hospital diagnosed COVID-19 patients.
●EMS COVID-19 Suspicion had a 20% positive
predictive value compared to hospital codes.
●EMS PPE use was documented at higher rates on
records that has a hospital COVID-19 diagnosis.
Clinical
Outcomes
12 Gregory et.
al
25
COVID-19
Vaccinations in EMS
Professionals:
Prevalence and
Predictors
Cross
Sectional
National Survey
of EMS
Professionals
US ●70% of EMS professionals are vaccinated in the US.
●The majority of those who did not receive the
vaccine reported concerns of safety as well as feeling
it was not necessary.
●84% of those who had not yet received the vaccine
do not plan to receive it in the future.
Perspectives/
Experiences
13 Ardebili et.
al
26
Healthcare
providers
experience of
working during the
COVID-19
pandemic: A
qualitative study
Qualitative Medical
Professionals of 3
major cities
IR ●4 major themes present in interviews included:
‘Working in the pandemic era’, ‘Changes in personal
life and enhanced negative affect’, ‘Gaining
experience, normalization and adaptation to the
pandemic’ and ‘Mental Health Considerations’.
Perspectives/
Experiences
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
14 Jaffe et. al
27
Responses of a Pre-
hospital Emergency
Medical Service
During Military
Conict Versus
COVID-19: A
Retrospective
Comparative
Cohort Study
Cohort Emergency
Ambulance Calls
to A National
EMS Organization
IL ●During conict call amounts decreased with an
increase in calls post-conit compared to pre-
conict.
●During COVID lockdown call amounts increased
with a decrease in calls post-conit compared to pre-
conict.
●There was a signicant decrease in MVC and other
injuries only during the lockdown.
Structural/
Systemic
15 Vanhaecht
et. al
28
COVID-19 is having
a destructive impact
on health-care
workers’ mental
well-being
Cross
Sectional
Survey of
Healthcare
workers in a cit.
Flanders, BE ●Negative psychological symptoms increased during
the pandemic and Positive symptoms were
experienced less frequently.
●18% of healthcare workers felt there was a need for
psychological guidance and 27% wanted more
leadership support.
●Strongest correlation between COVID-19 and
psychological symptoms was in 30–49 years, females,
nurses and residential care centers.
Mental
Health
16 Jensen et.
al
29
Strategies to Handle
Increased Demand
in the COVID-19
Crisis: A
Coronavirus EMS
Support Track and a
Web-Based Self-
Triage System
Cross
Sectional
City EMS Agency
Call Records
Copenhagen,
DK
●Total EMS call volume increased by 23.3% between
2019 and 2020.
●4.4% increase was seen in the 112 emergency line
and a 25.1% increase in the 1813 medical helpline.
●The wait time of the medical helpline increased from
2m:23s to 12m:2s from 2019 to 2020.
●There appears to be no correlation between call
volume and web triage system usage.
Structural/
Systemic
17 Firew et. al
30
Protecting the front
line: a cross-
sectional survey
analysis of the
occupational factors
contributing to
healthcare workers’
infection and
psychological
distress during the
COVID-19
pandemic in the
USA
Cross
Sectional
National survey
of healthcare
workers
US ●29% of respondents could be considered a probable
case from symptoms or test results.
●Healthcare workers with COVID-19 appear to have
higher levels of depressive symptoms.
●Emergency Department workers have the highest
likelihood of contracting COVID-19.
Mental
Health
18 Jouffroy et.
al
31
Hypoxemia Index
Associated with
Prehospital
Intubation in
COVID-19 Patients
Case Control Clinical care
reports of
COVID-19
patients cared for
by regional ALS
prehospital
service
Paris, FR ●A hypoxemia index (HI) < 1.3 correlated with a 3
fold increase in prehospital endotracheal intubation
of patients with COVID-19.
●Hypoxemia index may be a reliable indicator for
prehospital endotracheal intubation in respiratorily
compromised patients with COVID-19.
Clinical
Outcomes
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
19 Ventura et.
al
4
Emergency Medical
Services resource
capacity and
competency amid
COVID-19 in the
United States:
preliminary ndings
from a national
survey
Cohort Survey of
Practicing US
EMS clinicians
US ●There is a lack of knowledge among EMS providers
on the risk and transmission of COVID 19.
●There is a lack of equipment and PPE available to EMS
providers.
●EMS agencies are often not providing training or
resources to employees in regard to COVID-19.
Structural/
Systemic
20 Tabah et. al
32
Personal protective
equipment and
intensive care unit
healthcare worker
safety in the
COVID-19 era
(PPE-SAFE): An
international survey
Cross
Sectional
Survey
International
Healthcare
Workers
Global ●52% of Healthcare workers reported missing at least
one piece of PPE.
●30% report having to reuse single-use PPE.
●Signicant adverse effects from long PPE use was
reported.
Structural/
Systemic
21 Prezant et.
al
33
System impacts of
the COVID-19
pandemic on New
York City’s
emergency medical
services
Longitudinal City EMS Agency
Call Records
New York City,
US
●On March 30, 2020 call volumes increased 60%
compared to the same dates in 2019.
●The proportion of high acuity calls increased 42.3% in
2020 from 36.4% in 2019.
●High acuity call response time had an increase in
3min compared to low acuity calls which had an
increase of 11min.
●The most common call types were respiratory and
cardiovascular related.
Structural/
Systemic
22 Berry et. al
34
Helicopter
Emergency Medical
Services Transport
of COVID-19
Patients in the “First
Wave”: A National
Survey
Cross
Sectional
National Survey
of Helicopter
EMS services
US ●85% of programs reported that they chose to
transport known or suspected COVID-19 patients.
●93% reported providing COVID-19 training to its
providers.
●PAPR or N95 protective equipment was provided in
Covid-19 suspected cases by 77% of programs and
95% included pilots in distribution.
Transport
23 Xie et. al
35
Predicting Covid-19
emergency medical
service incidents
from daily
hospitalization
trends
Case Documented EMS
incidents within a
specic region
Texas, US ●On March 17th, the daily number of non-pandemic
EMS incidents dropped signicantly.
●On May 13th, the daily number of EMS calls climbed
back to 75% of the number in pre-Covid-19 time.
●For every 2.5 cases where EMS takes a Covid-19
patient to a hospital, one person is admitted.
●The mean daily number of non-pandemic EMS
demand was signicantly less than the period before
Covid-19 pandemic.
Clinical
Outcomes
24 Gonzalez et.
al
36
Proctologic
emergency
consultation during
COVID-19:
Comparative cross-
sectional cohort
study
Cross
Sectional
Retrospective
review of patient
data
ES ●191 patients were reviewed from 2019–2020.
●There was a 56% decrease in protocologic
emergency consultation, but the need for surgery
was 2x more frequent.
●There was no difference in outpatients regimen after
emergency surgery.
Clinical
Assessment
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
25 Greenhalgh
et. al
37
Where did all the
trauma go? A rapid
review of the
demands on
orthopaedic
services at a UK
Major Trauma
Centre during the
COVID-19
pandemic
Cohort Database of
Trauma Patients
at a Regional
Trauma Center
UK ●There was a 50.7% decrease in the number of
referrals to the orthopedic team.
●There was a 43.2% decrease in the number of trauma
operations carried out at the MTC trust.
●There was a 53.6% decrease in the number of
pediatric referrals.
●There was a 35.4% decrease in the number of major
trauma patients.
●Covid-19 had a big effect of the provision of trauma
and orthopedic surgery.
Clinical
Outcomes
26 Bourn et.
al
38
Initial prehospital
Rapid Emergency
Medicine Score
(REMS) to predict
outcomes for
COVID-19 patients
Cohort Prehospital and
hospital records
from ESO Data
Collaborative
Texas, US ●Initial prehospital Rapid Emergency Response Score
was modestly predictive of ED and hospital
dispositions for pts with Covid-19.
●Prediction was stronger for outcomes closer to the
rst set of EMS vital signs.
●In 13,890 Covid-19 pts, the median Rapid Emergency
Response Score was 6.
Clinical
Outcomes
27 Nishikimi et.
al
39
Intubated COVID-
19 predictive
(ICOP) score for
early mortality after
intubation in
patients with
COVID-19
Cohort Hospital medical
records of
Intubated patients
with COVID-19
New York City,
US
●The predictors of death within 14 days after
intubation included old age, hx of chronic kidney
disease, lower mean arterial pressure or increased
dose of required vasopressors, higher urea nitrogen
level, higher ferritin, higher oxygen index, and
abnormal pH levels.
Clinical
Outcomes
28 Feng et. al
40
Impact of COVID-
19 on emergency
patients in the
resuscitation room:
A cross-sectional
study
Cross
Sectional
Emergency room
patients in 2019
and 2020
Nanning, CN ●There was a decrease in the number of emergency
patients in the resuscitation room during the Covid-
19 Pandemic in intrinsic/extrinsic diseases and
pediatric cases.
●There was a decrease in the length of stay of
emergency patients in the resuscitation room.
●Comparison made between 2020 and 2019 in
Nanning, China.
Clinical
Outcomes
29 Garcia-
Castrillo et.
al
41
European Society
For Emergency
Medicine position
paper on
emergency medical
systems’ response
to COVID-19
Review Literature of
current and
previous
pandemic
recommendations
EU ●Current literature states that only critical patients
with COVID-19 should be admitted to the
emergency department.
●It is suggested that pre-hospital personnel be used to
perform initial assessment on COVID-19 patients
and possible contacts and if transportation or home
isolation is indicated.
●It is also stated that an additional consultation line
should not be used for noncritical cases instead of
the emergency line.
Structural/
Systemic
30 Albrecht et.
al
42
Transport of
COVID-19 and
other highly
contagious patients
by helicopter and
xed-wing air
ambulance: a
narrative review
and experience of
the Swiss air rescue
Review Air Ambulance
Crew Narratives
CH ●Lots of different means are being used for the
aeromedical transport of infectious pts.
●A method of transporting infectious pts are either
isolating/pt.
●Small Patient Isolation Units are benecial, ex:
transport can easily be changed without
contamination and still allowing access to pt.
Transport
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
31 US Centers
for Disease
Control &
Prevention
43
Interim Guidance
for Emergency
Medical Services
(EMS) Systems and
911 Public Safety
Answering Points
(PSAPs) for
COVID-19 in the
United States.
Centers for Disease
Control and
Prevention
N/A N/A US ●Face masks are used as an alternative to respirators
when the supply chain is low.
●Eye protection, gowns, and gloves should continue to
be worn.
●Recommended EPA-registered disinfectants are on a
reference list on the EPA website.
Structural/
Systemic
32 Yang et. al
44
Clinical
Characteristics of
Patients With
Coronavirus
Disease 2019
(COVID-19)
Receiving
Emergency Medical
Services in King
County,
Washington
Cohort COVID-19
patient records of
a country EMS
service
Washington,
US
●Most patients with Covid-19 who went to
emergency services were older and had multiple
chronic health conditions.
●Saying that Covid-19 is a febrile respiratory illness
does not necessarily t for early diagnostic suspicion,
at least for prehospital settings.
●As of June 1, 2020, mortality among the study cohort
was 52.4%.
Clinical
Assessment
33 Murphy et.
al
45
Occupational
exposures and
programmatic
response to
COVID-19
pandemic: an
emergency medical
services experience
Cohort Mixed Washington,
US
●Of 700 EMS clinicians 0.4% tested positive during the
duration of the investigation.
●Less than 0.5% experienced COVID related illness
within 14 days of exposure.
Perspectives/
Experiences
34 Spangler et.
al
46
Prehospital
identication of
Covid-19: an
observational study
Observational Patient care
reports
Uppsala, SE ●Patients who tested positive for Covid-19 had worse
outcomes than those who tested negative.
●30 day mortality rates were 24% vs 11% in Covid-19
positive vs negative.
●Suspicion of Covid-19 in a prehospital setting should
not be solely relied on to rule out using isolation
precautions.
Clinical
Assessment
35 Albright et.
al
47
A Dispatch
Screening Tool to
Identify Patients at
High Risk for
COVID-19 in the
Prehospital Setting
Case Control Prehospital care
reports and
electronic health
charts
Massachusetts,
US
●In MA, the rate of positive Covid-19 tests was 2%.
●Reporting shortness of breath was the most
common symptom that resulted in a positive
screening for Covid-19.
●Most positive tests did not belong to high-risk
populations.
Dispatch/
Activation
36 Cash et. al
48
Emergency Medical
Services Personnel
Awareness and
Training about
Personal Protective
Equipment during
the COVID-19
Pandemic
Cross-
sectional
Mixed US ●Despite increased CDC guidance for N95 t testing
for EMS, there are still substantial gaps in PPE training
use among EMS.
●Part-time workers, 911 response service, working at
non-re based EMS services, and working in rural
areas are associated with lower odds of awareness/
training.
Perspectives/
Experiences
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
37 Moeller et.
al
49
Symptom
presentation of
SARS-CoV-2-
positive and
negative patients: a
nested case-control
study among
patients calling the
emergency medical
service and medical
helpline
Case Clinical data from
patient care
reports
Copenhagen,
DK
●Loss of smell/taste as a symptom of Covid-19 was
almost always reported for patients younger than 60.
●Fever and cough were the most common symptoms
in all age groups.
●Loss of appetite and feeling unwell were symptoms
that were more common for patients over 60 years
old.
Clinical
Assessment
38 Jouffroy et.
al
50
Prehospital
management of
acute respiratory
distress in
suspected COVID-
19 patients
Cohort EMS and Hospital
Patient Care
Records
Paris, FR ●15% of 256 patients with COVID-19 symptoms
died at the scene but there was a low prevalence
of prior cardiovascular risk factors.
●Out of the 185 patients analyzed 44% were
transported via BLS and 42% received non-
invasive ventilation.
●56% were transported via ALS and 52% of these
patients received noninvasive ventilation and 18%
received intubation.
Treatment
39 Shekhar et.
al
51
COVID-19 and the
Prehospital
Incidence of Acute
Cardiovascular
Events (from the
Nationwide US
EMS)
Mixedl Mixed US ●10.33% decrease in EMS calls between January and
March 2020.
●4.62% decrease from February to March 2020.
●STEMI and CVA alerts decreased across all months.
●Incidence of VF/VT and asystole decreased from
January to March, but increased from March to April.
Clinical
Outcomes
40 Glenn et.
al
52
Refusals After
Prehospital
Administration of
Naloxone during
the COVID-19
Pandemic
Cohort Incidences of
refusals following
naloxone
administration
US ●The amount of patients that refused transport
following prehospital administration of naloxone
increased during the pandemic.
●During the COVID-19 pandemic, over twice as
many patients who received naloxone in a
prehospital setting refused transport than prior to
the pandemic.
●29.7% of patients who did not receive naloxone
refused transport prior to the pandemic, while
41.3% refused during the pandemic.
Clinical
Outcomes
41 Jarvis et. al
53
Examining
emergency medical
services’ prehospital
transport times for
trauma patients
during COVID-19
Cohort Trauma patients
transported via
EMS to six US
trauma centers
US ●There was no signicant difference in total EMS
prehospital times between 2019 and during COVID-
19 pandemic.
●Times during transport were less during the
pandemic than in 2019.
●Less trauma patients were transported during the
pandemic than in 2019.
Transport
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
42 March et.
al
54
Effects of COVID-
19 on EMS
Refresher Course
Completion and
Delivery
Case Commission
Accreditation for
Prehospital
Continuing
Education
database of
continuing
education
records
US ●There was a 179% increase in completion of EMS
refresher courses from 2018 to 2020.
●There was a 185% increase in asynchronous
online refresher course completion from 2018 to
2020.
●No signicant difference in mean monthly live in person
and virtual instructor-led training in the months between
2018 and 2020.
●Study suggests EMS refresher course completions
are more likely when given via asynchronous
methods rather than live in person methods as a
result of the COVID-19 pandemic.
Education
43 Saberian et.
al
55
How the COVID-
19 Epidemic
Affected Prehospital
Emergency Medical
Services in Tehran,
Iran
Case Control Records of EMS
activations,
employees, and
time codes
Tehran, UQ ●Tehran prehospital personnel experienced a 347%
increase in EMS calls and 21% increase in EMS
dispatches.
●After the onset of the COVID-19 pandemic, Tehran
EMS saw an increase in chief complaints of fever by
211% and respiratory distress by 245%.
●To keep up with the increased EMS demand, Tehran
increased the amount of EMS providers available,
decreased time between shifts, and raised amount of
overtime hours.
●In-service education continued during the pandemic.
Structural
/Systemic
44 Oulasvirta
et. al
56
Paediatric
prehospital
emergencies and
restrictions during
the COVID-19
pandemic: a
population-based
study
Cohort EMS contacts
involving children
between 0 and 15
years old
Helsinki, FL ●There was a decrease in pediatric EMS calls by
30.4% from March 2020 to May 2020.
●After the onset of the pandemic, a majority of
pediatric EMS contacts were a result of trauma
or a need for intensive care.
●There was a decrease in number of transports of
pediatric patients following contact with EMS
personnel after onset of the pandemic.
●Pediatric patients that made contact with EMS
were more likely to be critically ill between
March 2020 and May
2020 than prior to this period.
Special
Populations
45 Hadley et.
al
57
911 EMS
Activations by
Pregnant Patients in
Maryland (USA)
during the COVID-
19 Pandemic
Retrospective Records of EMS
calls related to
obstetric
emergencies
Maryland, US ●There was a decrease in EMS calls in response to
obstetric issues during
the pandemic than was seen in the months prior.
●High fraction (as compared to population
demographics) of obstetric-related EMS calls were
from African-American women during the pandemic.
●Percent of EMS contacts with female patients
remained unchanged in the periods during and prior
to the pandemic.
Special
Populations
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
46 Hart et. al
58
Recommendations
for Prehospital
Airway Management
in Patients with
Suspected COVID-
19 Infection
Systematic
Review
Peer-reviewed
literature
US ●Providers should always don and secure Personal
Protective Equipment (PPE) prior to making
contact with a patient suspected of having
COVID-19.
●EMS should not try endotracheal intubation more
than once, as to prevent additional exposure to
infection, and should attempt with video
laryngoscopy rather than direct
laryngoscopy if possible.
●After ET or SGA placement, HEPA lter should
be placed on ET tube or SGA to prevent
potential COVID-19 exposure to other
equipment.
●For BLS crews who are unauthorized to perform
intubation or SGA placement techniques, it is
recommended to perform two-person
resuscitation techniques to ensure a tight seal of
BVM on patient’s mouth to prevent
contamination.
Treatment
47 Mohammadi
et. al
59
Management of
COVID-19-related
challenges faced by
EMS personnel: a
qualitative study
Qualitative Detailed
interviews with
pre-hospital
emergency care
personnel
IR ●EMS providers are unsure how to approach
patients suspected of COVID-19 infection due to
a lack of standard, comprehensive treatment
protocols.
●EMS personnel experience psychological strain as
a result of inadequate equipment and increased
work hours during the COVID-19 pandemic.
●EMS personnel are frustrated with the lack of
public education of COVID-19 which leaves many
patients unable to take proper precautions to
prevent exposing providers to infection.
Perspectives/
Experiences
48 Lancet et.
al
60
Prehospital
hypoxemia,
measured by pulse
oximetry, predicts
hospital outcomes
during the New
York City COVID-
19 pandemic
Longitudinal Adult patients
transported by
EMS in NYC
New York, US ●Prehospital oxygen saturation level is an indicator of
mortality and length of stay in hospital.
●In patients over 65 years old, an oxygen saturation
above 90% showed a 26% chance of death in hospital,
while a saturation below 90% showed a 54% chance
of death.
●In patients under 66, a prehospital oxygen saturation
above 90% revealed 11.5% chance of death, while
oxygen saturation under 90% revealed a 31% chance
of death in hospital.
Clinical
Outcomes
49 Powell et.
al
61
Prehospital Sinus
Node Dysfunction
and Asystole in a
Previously Healthy
Patient with
COVID-19
Case Female with nodal
dysfunction and
asystole following
COVID-19
infection
US ●A 47 year old patient with no history of prior illness
experienced nodal dysfunction and asystole episodes,
characterized by hypoxia due to pneumonia.
●Post-recovery, no other arrhythmias were observed.
Clinical
Assessment
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
50 Velasco et.
al
62
Impact of COVID-
19 Pandemic on the
Incidence,
Prehospital
Evaluation, and
Presentation of
Ischemic Stroke at a
Nonurban
Comprehensive
Stroke Center
Retrospective Patients
presenting with
ischemic stroke
symptoms as
obtained by
prehospital
quality
improvement
database
US ●There was a decrease in the number of transports of
patients experiencing stroke symptoms from 2019 to
2020.
●The median amount of transport time between EMS
dispatch and hospital arrival for patients diagnosed
with a stroke increased from 2019 to 2020.
●There is a decrease in patient transport volumes and
increase in time taken to access appropriate care
from 2019 to 2020 in nonurban areas.
Clinical
Outcomes
51 Solà-Muñoz
et. al
63
Impact on
polytrauma patient
prehospital care
during the rst
wave of the
COVID-19
pandemic: a cross-
sectional study
Cross
Sectional
Records of EMS
activations as a
result of
polytrauma
patients
Catalonia, ES ●There was a 52% decrease in polytraumatic
patients treated after the onset of the pandemic.
●There was a decrease in EMS dispatches to trafc
accidents and pedestrian-vehicle collisions from
before the pandemic to the rst few months of
the pandemic.
●There was an increase in injuries caused by
weapons and burns after the onset of the
pandemic.
●The COVID-19 pandemic decreased the amount
of polytraumatic patients treated by EMS, and saw
a difference in the severity and category of
trauma.
Clinical
Outcomes
52 Siman-Tov
et. al
64
An assessment of
treatment,
transport, and
refusal incidence in
a National EMS’s
routine work during
COVID-19
Comparative Patient care
reports
IL ●Incidence of infectious disease, cardiac arrest,
psychiatric, and labor and delivery calls increased
from March and April 2019 to 2020
●Incidence of neurology and trauma calls decreased in
the same period.
●Refusal by patients for transport to a hospital
increased from 13.4% to 19.9%, accompanied by an
increase in deaths 8 days post-refusal.
Structural/
Systemic
53 Marincowitz
et. al
65
Prognostic accuracy
of triage tools for
adults with
suspected COVID-
19 in a prehospital
setting: an
observational
cohort study
Cohort Patient care
reports
GB ●65% of patients were transported to hospital and
EMS decision to transfer patients achieved a
sensitivity of 0.84.
●NEWS2, PMEWS, PRIEST tool and WHO algorithm
identied pts at risk of adverse outcomes with a high
sensitivity.
●Using NEWS2, PMEWS, PRIEST tool, and the WHO
algorithm can improve sensitivity of EMS triage of
patients with suspected COVID-19 infection.
Clinical
Assessment
54 Ong et. al
66
An international
perspective of out-
of-hospital cardiac
arrest and
cardiopulmonary
resuscitation during
the COVID-19
pandemic
Comparative Mixed Global ●Studies in Italy, New York City, and France showed a
signicant increase in out-of-hospital cardiac arrests
with the arrival of the pandemic.
●The difculties that the rst responder system faced
during Covid-19 were dispatcher overload, increased
response times, and adherence to PPE requirements,
superimposed on PPE shortages.
●New noninvasive, adjunct tools, warrant
consideration with the rise in OCHA during the
pandemic.
Perspectives/
Experiences
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
55 Yu et. al
67
Impact of the
COVID-19
pandemic on
emergency medical
service response to
out-of-hospital
cardiac arrests in
Taiwan: a
retrospective
observational study
Observational Patient care
reports
TW ●There was a longer EMS response time for patients
with out-of-hospital cardiac arrests during the
pandemic.
●The rate of prehospital ROSC was lower in 2020.
●Signicantly fewer cases had favorable neurological
function in 2020.
Structural/
Systemic
56 Azbel et. al
68
Effects of the
COVID-19
pandemic on
trauma-related
emergency medical
service calls: a
retrospective
cohort study
Cohort Patient care
reports
FL ●During lockdown, there was a 12.2% decrease in the
number of weekly total EMS calls.
●There was also a 23.3% decrease in the number of
weekly trauma related calls
●There was also a 41.8%. decrease in the weekly
number of injured patients met by EMS while
intoxicated with alcohol.
●After the lockdown, numbers returned to normal
pre-lockdown.
Clinical
Outcomes
57 Seo et. al
69
Pre-Hospital Delay
in Patients With
Acute Stroke
During the Initial
Phase of the
Coronavirus
Disease 2019
Outbreak
Cohort Patient care
reports
Seoul, KR ●In the initial phase after the Covid-19 outbreak, EMS
response times for acute strokes were delayed.
●Clinical outcomes of patients with acute stroke
deteriorated.
●The ICU admission and mortality rate increased in
the early phase of the Covid-19 outbreak.
Clinical
Outcomes
58 Mälberg et.
al
70
Physiological
respiratory
parameters in pre-
hospital patients
with suspected
COVID-19: A
prospective cohort
study
Cohort Clinical data from
patient care
reports
Uppsala, SE ●The odds of having COVID-19 increased with higher
respiratory rate, lower tidal volume and negative
inspiratory pressure.
●Patients taking smaller, faster breaths with less
pressure had higher odds of having COVID-19.
●Smaller, faster breaths and higher dead space
percentage increased the odds of hospital admission.
Clinical
Assessment
59 Ng et. al
71
Impact of COVID-
19 ‘circuit-breaker’
measures on
emergency medical
services utilisation
and out-of-hospital
cardiac arrest
outcomes in
Singapore
Case control Patient care
reports
SG ●EMS call volume and total out-of-hospital cardiac
arrests remained comparable to past years.
●There was a decline in prehospital ROSC rates, but
not statistically lower than pre-COVID periods.
●There is a growing body of literature internationally
on the potential impact of the COVID-19 pandemic
on EMS utilization and outcomes.
Clinical
Outcomes
60 Cash et. al
72
Emergency medical
services education
research priorities
during COVID-19:
A modied Delphi
study
Case Mixed US ●The top 4 research priorities were prehospital
internship access, impact of lack of eld and clinical
experience, student health and safety, and EMS
education program availability and accessibility.
Education
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
61 Borkowska
et. al
73
Out-of-hospital
cardiac arrest
treated by
emergency medical
service teams
during COVID-19
pandemic: A
retrospective
cohort study
Cohort Clinical data from
patient care
reports
PL ●The average age of patients with out-of-hospital
cardiac arrest was 67.8 years.
●Among resuscitated patients, 73.8% were cardiac
etiology. 9.4% of patients had ROSC, 27.2% of
patients were admitted to hospital with ongoing
chest compression.
●In the case of 63.4% cardiopulmonary resuscitation
was ineffective and death was determined.
●The presence of shockable rhythms was associated
with better prognosis.
Clinical
Outcomes
62 Kalani et.
al
74
Self-Referred Walk-
in (SRW) versus
Emergency Medical
Services Brought
Covid-19 Patients
Cohort Mixed Jahrom, IR ●27.1% of COVID-19 patients in the ER were brought
in by EMS while 72.9% were self referred walk ins.
●Survival rates were lower among patients brought in
by EMS.
●Critically ill patients were more likely to utilize EMS
therefore EMS usually brought in patients with lower
chances of survival.
Clinical
Outcomes
63 Talikowska
et. al
75
No apparent effect
of the COVID-19
pandemic on out-
of-hospital cardiac
arrest incidence and
outcome in
Western Australia
Case Control Incidences of
OOHCA events
AU ●There was no signicant change in the number of
OOHCAs during the 2020 period compared to a
period of similar length in 2017.
●There was no signicant change in bystander CPR
rates between the two periods.
●There was no signicant change in survival rates for
OOHCAs.
Clinical
Outcomes
64 Saberian et.
al
76
Changes in COVID-
19 IgM and IgG
antibodies in
emergency medical
technicians (EMTs)
Correlational Acquired clinical
data
Tehran, IR ●There were less seropositive participants than
seronegative ones.
●9.5% only tested positive for IgG.
●1.1% were only positive for IgM.
●32.4% were positive for both.
●There was a signicant. reduction is seropositivity
after the second phase.
Clinical
Outcomes
65 Ageta et. al
77
Delay in Emergency
Medical Service
Transportation
Responsiveness
during the COVID-
19 Pandemic in a
Minimally Affected
Region
Case Patient care
reports
Okayama, JP ●Prehospital time can be divided into three
components: response time, on-scene time, and
transportation time.
●The duration of response time and on-scene time
increased in April 2020 from April 2019 from 32.2 to
33.8 minutes and 8.7 to 9.3 minutes, respectively (p <
0.001).
●However, there was no signicant change in duration
of transportation.
Transport
66 Hunt et. al
78
Novel Negative
Pressure Helmet
Reduces
Aerosolized
Particles in a
Simulated
Prehospital Setting
Experimental Particle counts Michigan, US ●A personal negative pressure helmet (“AerosolVE”)
was developed to lter and trap virus particles from
the patient.
●The amount of particles trapped inside the helmet
were signicantly higher than those outside.
●An average of less than one particle was found
externally to the lter.
Prevention
(Continued)
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Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
67 Tanaka et.
al
79
Evaluation of the
physiological
changes in
prehospital health-
care providers
inuenced by
environmental
factors in the
summer of 2020
during the COVID-
19 pandemic
Correlational Acquired clinical
data
JP ●A positive correlation was found between WGBT,
and pulse rate.
●Forehead temperature increased upon entrance to a
33°C environment.
●Hot environments posed a higher risk of heat stroke
while wearing PPE.
Clinical
Outcomes
68 Melgoza et.
al
80
Emergency Medical
Service Use Among
Latinos Aged 50 and
Older in California
Counties, Except
Los Angeles, During
the Early COVID-
19 Pandemic Period
Cohort Data from the
California
Emergency
Medical Services
Information
System (CEMSIS)
California, US ●Latinos are disproportionately affected by the
COVID-19 pandemic, as they make up 32% of the
Californian population, but comprised 52% of
COVID-19 cases and 64% of COVID-19 deaths.
●Latinos also comprised a larger proportion of
respiratory distress calls than Whites, but a
statistically signicant smaller proportion than Blacks.
Special
Populations
69 Goldberg et.
al
81
Home-based Testing
for SARS-CoV-2:
Leveraging
Prehospital
Resources for
Vulnerable
Populations
Case Case Study US ●An EMS-created COVID-19 home testing program
was established.
●From its inception to April 2020, the program had
tested 477 homebound patients, with an average of
about 15 per day.
●Mass testing locations were also established for up to
900 tests per day.
Prevention
70 Saberian et.
al
82
The Geographical
Distribution of
Probable COVID-
19 Patients
Transferred by
Tehran Emergency
Medical Services; a
Cross Sectional
Study
Cross-
sectional
Electronic patient
care data
Tehran, IR ●The mean age of patients increased over the three
month study period, from 53.2 to 54.5 to 56.0.
●The average incidence rate of COVID-19 was 4.6 per
10,000 people, with municipalities varying greatly in
incidence.
Transport
71 Tušer et. al
83
Emergency
management and
internal audit of
emergency
preparedness of
pre-hospital
emergency care
Case Mixed CZ ●Documents, communications technology, and
processes for identication in triage are not uniform
across the nation.
●Healthcare providers and staff are ill-informed on
resource points in life-threatening (for themselves or
the patient) situations.
Structural/
Systemic
72 Masuda et.
al
84
Variation in
community and
ambulance care
processes for out-
of-hospital cardiac
arrest during the
COVID-19
pandemic: a
systematic review
and meta-analysis
Meta-analysis Peer-reviewed
Literature
US ●Out-of-hospital sudden cardiac arrest was more
common throughout the COVID-19 pandemic, with
an odds ratio of 1.38.
●Debrillation by bystanders while waiting for an EMS
response was signicantly lower (OR = 0.69).
●Delays in EMS arrival were more common.
Structural/
Systemic
(Continued)
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Discussion
Structural Considerations
Of the studies selected for inclusion in the “structural/systemic” domain, only 25% pertained to regions within the US.
Only one study at the start of the pandemic (April 2020) rigorously assessed resource capacity and clinical competency at
Table 1 (Continued).
# Author(s) Title Design Sample Country/
Region
Summary of Key Findings Primary
Domain
73 Hasani-
Sharamin et.
al
85
Characteristics of
Emergency Medical
Service Missions in
Out-of-Hospital
Cardiac Arrest and
Death Cases in the
Periods of Before
and After the
COVID-19
Pandemic
Cross-
sectional
Mission data Tehran, IR ●The number of OOHCAs in 2019 was greater than
that of 2018 or 2020.
●Respiratory distress and infection were more
common in 2020 than 2019.
●History of diabetes, hypertension, and heart disease
was more common in 2020.
Clinical
Outcomes
74 Jaffe et. al
86
The Role of Israel’s
Emergency Medical
Services During a
Pandemic in the
Pre-Exposure
Period
Case Mixed IL ●Out of 121 protected transports, 36.3% were
referred to by medical sources.
●Out of 121 protected transports, 63.7% were
identied as “suspected COVID-19” by dispatchers.
●EMS can work effectively in the pre-exposure period
through instructing home quarantine, providing
protected transport, and stafng border control
checkpoints.
Structural/
Systemic
75 Masterson
et. al
87
Rapid response and
learning for later:
establishing high
quality information
networks and
evaluation
frameworks for the
National Ambulance
Service response to
COVID-19 - The
ENCORE COVID
Project Protocol
Case Survey responses
from a national
ambulance
service
IE ●The aim of this project was to disseminate pandemic
related information using an evidence based
framework.
●The project intends to systematically evaluate
information frameworks for the Irish National
Ambulance Service.
Structural/
Systemic
76 Le Borgne
et. al
88
Pre-Hospital
Management of
Critically Ill Patients
with SARS-CoV-2
Infection: A
Retrospective
Multicenter Study
Cohort Patient
enrollment from
regiospecic EMS
calls
FR ●Of patients with suspected COVID-19 no difference
was found in hospital mortality between silent
hypoxemia and hypoxemia with clinical acute
respiratory failure.
●53.4 of patients suspected to have COVID-19
presented with signs of respiratory distress
●All patients presenting with COVID-19 symptoms
required high ow oxygen therapy.
Treatment
77 Natalzia et.
al
89
Evidence-based
crisis standards of
care for out-of-
hospital cardiac
arrests in a
pandemic
Cohort Cardiac arrest
events in the
CARES database
US ●Favorable outcomes were associated with initial
shockable rhythms or arrest witnessed by EMS.
●A proposed crisis standard of care protocol
suggested to only initiate out-of-hospital
resuscitation in these patients resulted in a
prevalence of 70.5% favorable neurological
outcomes.
●Incidences of favorable neurological outcome
correlated with 6.3 free available beds
Treatment
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the national level, in response to the COVID-19 pandemic. Study participants were licensed practicing EMS clinicians in
all 50 US states including the District of Columbia. Ventura et al report regular dissatisfactory decontamination practices
both prior to and during the pandemic, required prolonged use of N95 respirators past the recommended efcacy period,
and overall inadequate education for infection control and clinical considerations for COVID-19 patients.
4
Notably, this
captures a vulnerable representation of the US EMS system when there was minimal consensus on COVID-19 clinical
symptomatology, transmissibility, appropriate precautionary measures, and discovery of vaccines. Globally, highly
populated regions in the US, Germany, Turkey, Ireland and Denmark observed an increase in emergency medical calls
of varying chief complaints, with many agency and regiospecic ambulance agencies reporting call volumes exceeding
60% compared to 2019.
14,16,33
Based upon analysis of 911 de-identied patient care reports from the National EMS
Information System (NEMSIS), between January 2018 to December 2020, Methley et al report an increase in frequency
of on-scene death (1.3% to 2.4%), cardiac arrest (1.3% to 2.2%), and opioid related emergencies (0.6% to 1.1%) at the
national level.
6
States such as Kentucky observed higher rates of opioid related 911 calls, with a 50% increase in
suspected opioid overdose death calls, while calls for other chief complaints remained static or declined.
14
This is
consistent with an apparent national trend of a worsening opioid epidemic, which we hypothesize has been only
exacerbated by COVID-19. In February 2022, the American Medical Association issued a statement alleging an increase
in drug related deaths in all US states and territories.
90
To that end, it is critical to acknowledge that recent studies suggest
black and brown communities are likely to be disproportionately harmed by both the opioid epidemic and the COVID-19
pandemic, as rates of morbidity and mortality are generally higher in this clinical population.
91–94
Because EMS
clinicians are crucial in overdose resuscitation and sustaining life of patients experiencing opioid overdose, prehospital
providers may be uniquely responsible for understanding foundational systemic issues, such as racial inequity, and how
they translate to emergency clinical care, which is not currently requisite by national EMS curriculum standards despite
the measurable impact of care and access disparities experienced by patients of color.
95–105
Mental Health
It has been well established in the literature that the COVID-19 pandemic has correlated with worse mental health
outcomes in healthcare workers (HCWs).
20
The strongest correlation among COVID-19 and psychological symptoms
appeared in female-identifying HCWs ages 30–49 years.
28
There is a continued need for strong psychological support
and further investigation into determinants of poor mental health outcomes to develop evidence driven preventive
measures.
EMS Activation
911 dispatchers at public safety answering points (PSAPs) are critical to functional operations of the EMS system.
Albright et al investigated the efcacy of a dispatch screening tool to identify high suspicion of COVID-19 in patients
based upon a questionnaire deployed by the 911 call taker in a study based in Massachusetts. The authors report a
sensitivity of 74.9% (CI, 69.21–80.03) and a specicity of 67.7% (CI, 66.91–68.50) where n=263.
47
Amiry and Maguire
report an exponential increase in emergency medical calls globally during the pandemic, so further investigation into
ways PSAPs can best support responding clinicians using evidence based practices may be warranted.
21
Clinical Assessment, Treatment, and Outcomes
In a cohort study based in King County, Washington, US, Yang et al found that EMS responded to approximately 16% of
COVID-conrmed cases. From study initiation to June 2020 (four months), the study cohort mortality was 52.4%. Fever,
tachypnea, and hypoxia was only present in a limited quantity of patients.
44
This is consistent with international
prehospital consensus that suspicion of COVID-19 based solely on symptomatology should not be solely relied on for
contemplating precautionary measures and isolation procedures. In a prehospital study in Denmark, patients under 60
years old were more likely to present with a loss of taste and/or smell upon assessment, however fever and cough were
equally distributed across all age groups.
49
In England, Marincowitz et al studied the accuracy of prognostic triage tools
used prehospitally in the Yorkshire and Humber region. The WHO algorithm, PRIEST, NEWS2, and PMEWS tools all
had high sensitivity for detecting COVID-19 infection.
65
In Uppsala, Sweden, Mälberg et al report correlational ndings
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of physiological respiratory parameters with patients suspected of having COVID-19. They found that the odds of
COVID-19 diagnosis increased with respiratory rate, lower tidal volume, and negative inspiratory pressure.
65
In Paris,
France, Jouffroy et al report that pulse oximetry may be a reliable indicator for the need of mechanical ventilation in
COVID-19 patients.
38
It is important to acknowledge, however, that clinically signicant inaccuracy of pulse oximetry
for detecting hypoxia in darker skin patients has been well established in the literature.
106,107
While many methods for
assessing risk of COVID-19 infection exist, a universal guidance for prehospital assessment has not been established.
As COVID-19 is categorized as a respiratory illness, the majority of available articles on prehospital treatment had a
signicant focus on airway and breathing management. A study out of Paris reported that of the 15% of suspected
COVID-19 patients who were found to be in cardiac arrest upon arrival, while the majority did not have prior
cardiovascular risk factors present. This suggests that it is critical to provide sufcient respiratory support in the
prehospital setting. It was found that of the suspected COVID-19 patients who were assessed by EMS personnel, 42%
of BLS cases and 52% of ALS cases provided non-invasive ventilation, however, prehospital intubation was signicantly
less common as it was only present in 18% of ALS cases.
50
, Jouffroy et al report that of all COVID−19 suspected
patients, 53.4% showed signs of respiratory distress. Most of these patients presented with respiratory rates of
approximately 30/min and oxygen saturations of 72%. Additionally, all patients required some method of high ow
oxygen treatment.
88
Studies, such as one conducted by Hart et al, provides recommendations for personal protection protocols for EMS
providers. They suggest that if endotracheal intubation is needed, it should only be attempted once and with the
assistance of video laryngoscopy to minimize time exposure to aerosols. A HEPA lter should then be added following
the placement of an advanced airway to further minimize risk for contamination of the provider and all other equipment
present in the ambulance. In the event that advanced airway intervention is not possible or clinically indicated, it is
suggested to use two individuals for BVM ventilation to ensure that an air-tight seal is made with the mask. In agreement
with other established protocols, they stress that donning of PPE should be performed before any contact is made with a
suspected COVID-19 patient.
58
As mentioned previously, there is a shortage of available resources not just pre-hospital but in-hospital as well.
Considerations need to be made to ensure resources are used in the most efcient manner. Natalzia et al proposes a
protocol to maximize cardiac arrest resources in EMS in which one should only initiate resuscitation of a patient in
cardiac arrest if the arrest is witnessed or a shockable rhythm is present. They state that this protocol could account for
70.5% of favorable neurological outcomes and provide 6.3 additional available hospital beds per patient.
89
Education
As part of their initial education program, EMS students must generally acquire co-requisite eld experience.
1
During the
early era of the COVID-19 pandemic, it may have been difcult to participate in eld experience opportunities due to
facility policy limitations designed to reduce transmission. Grawey et al examined an alternative model to the traditional
ambulance “ride along” by providing a eld-like experience in an emergency department setting. Grawey et al report that
this alternative experience was likely as effective as traditional prehospital clinical internships. Additionally, they found
university medical students to have increased knowledge regarding EMS roles and responsibilities, which may have
benecial implications for transfer of care.
23
With regard to continuing education, the Commission on Accreditation for
Prehospital Continuing Education (CAPCE) saw a 179% increase in EMS refresher courses during 2018 to 2020, with a
185% increase in asynchronous online learning.
54
This may suggest that distance learning as a method for recertifying
provider credentials may increase rates of recertication, in contrast with in-person continuing education programs.
Vaccine Perspectives and Prevalence
US EMS clinicians have also assumed nontraditional healthcare roles during the COVID-19 pandemic, such as in the
case of a scope of practice expansion which allowed EMS clinicians to administer the COVID-19 to patients in states like
New York, Massachusetts, and Vermont. Because EMS clinicians are highly trained in specic psychomotor clinical
skills and knowledgeable in fundamental methods of patient assessment and treatment, it is likely that EMS in general
has served unmeasurable utility through contributions in traditional and nontraditional roles. In April 2021, Gregory et al
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conducted a cross sectional study of nationally certied EMS clinicians rostered with the National Registry of Emergency
Medical Technicians (NREMT). Of a sample size of n=2584, 70% reported receiving a COVID-19 vaccine. Of the
sampled population, 53% had concerns regarding the safety of COVID vaccines, 39% felt it was not necessary, and 84%
of providers who did not receive any dose of the COVID vaccine did not plan to get it in the future.
25
The signicant
vaccine hesitancy amongst EMS clinicians poses a compelling public health concern, and approaches to mediate this,
such as through local education and role modeling, may be necessary.
108
Limitations
Little literature exists on the interrogated area of investigation, and studies that are relevant to the area are often
preliminary and may require continued study and design modications to increase external validity. While all attempts to
achieve a high level of internal validity were made as captured by robust quality assessments at each level of
investigation, it was not possible to accommodate for every confounder. While this review is not exhaustive, the authors
afrm satisfaction in the methods and results available at the time of study.
Conclusion
US EMS clinicians are healthcare workers that have often held many roles and responsibilities during the COVID-19
pandemic. Within the subset domains of i. structural/systemic, ii. clinical outcomes, iii. clinical assessment, iv. treatment,
v. special populations, vi. dispatch/activation, vii. education, viii. mental health, ix. perspectives/experiences, and x.
transport, there is minimal high quality literature that faithfully reect the status of modern American EMS in response to
the COVID-19 pandemic. The available data reect strides in contemporary approaches to assessment, treatment,
transport, and education, but fall short in accounting for care and access disparities inuenced by social determinants.
Continued investigation on the impact of COVID-19 on EMS systems and personnel is warranted to ensure informed,
appropriate, and evidence-based preparation for future pandemic and infectious disease response.
Institutional Disclaimer
The work is solely that of the authors and does not necessarily represent the views, policies, or opinions of their afliated
institutions, employers, or partners. It was not reviewed or endorsed by any specic institution in particular.
Acknowledgments
The authors would like to sincerely thank Paramedic Catherine Smith, EMT Rosa Turinetti, and Judith Inumerable for
their expert opinions and experiences.
Author Contributions
All authors contributed to data analysis, drafting or revising the article, have agreed on the journal to which the article
will be submitted, gave nal approval of the version to be published, and agree to be accountable for all aspects of the
work.
Funding
The work is not funded by any specic source.
Disclosure
The investigators report no known conicts of interest, nancial or otherwise.
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