Breaking the Chain of Survival? The Impact of COVID-19 on Prehospital Care

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Hospitals, labs, and doctor’s offices clearly play the central role in the COVID-19 conversation in the national media and in various medical journals. While this is understandable, the impact of the pandemic on prehospital services needs greater consideration. Ambulance companies, fire departments, and even police officers represent an essential piece of the healthcare system, often serving as gateway providers on critical out-of-hospital events. The pandemic’s havoc wrought on the prehospital community may have downstream effects on the efficacy of the overall healthcare system which should be considered.

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Across the nation, fire-rescue agencies serve in a first response, prehospital medical role, fielding hundreds of thousands of first aid-CPR certified responders, emergency medical technicians, paramedics and even nurses. They also come into contact with the pandemic and its aftereffects on a daily basis. As a consequence, the International Association of Fire Chiefs (IAFC) has set up its own COVID-19 tracking system to gather statistics, oriented toward understanding the impact of the pandemic on fire-rescue departments. The dashboards look at issues like staffing and finance in an attempt to quantify the impact and provide a means of charting a course through the pandemic and the subsequent recovery.

The reported impact of the COVID-19 situation, thus far, is staggering. Between March 1 and August 31, 2,275 departments reported to IAFC’s Personnel Impact dashboard.1 The vast majority were from American fire-rescue agencies. Over this five-month period, reporting departments saw 15,034 exposures, 12,599 quarantined, and 874 employees/volunteers diagnosed with COVID-19. This absence of 15,000 firefighters from nearly 2,300 reporting departments represents a tremendous impact on the communities they serve. It represents engines running short-staffed impacting more than just emergency medical services (EMS). It represents stations being browned out (temporarily closed) due to COVID-related staffing shortages or even due to contamination of the station itself.

The IAFC also has a dashboard that looks at the financial impact of this event on departments across the nation.2 Again, this data represents the period between March 1 and August 31 and draws from 884 reporting departments. The concerns fall into two main categories: excessive unplanned spending on COVID-19 related activities, and the impact of decreased revenue due to a slowing economy and extended stay-at-home orders. On the unplanned expense front, as of the beginning of June 2020, departments reported a 29% increase on spending due to COVID-19. The pandemic’s reported budget impact in 2020 is $1,869,901,597. The anticipated loss is expected to increase to $2,037,880,205 in 2021. Because of these budget shortfalls, the reporting departments are anticipating furloughing 458 uniformed staff and 603 civilians in 2020. This increases to 630 uniformed and 1,911 civilians in 2021. When coupled with the direct personnel impact of the pandemic through sickness and quarantines, this could create a tremendous service gap.

It should be noted that, according to the IAFC’s breakdown of the reporting departments, 82% of the data is drawn from all-career and volunteer-career combination departments. A current survey of fire departments by the U.S. Fire Administration shows career and combination departments represent only 28% of the total agencies nationwide,3 which makes this data even more concerning. Volunteer departments (the other 72%) that were already holding bake sales to buy used fire engines can only absorb so much financial impact before the side effects metastasize throughout the community’s prehospital care system.

Ambulance companies have similar concerns. In Georgia, private ambulance services are facing the threat of depleted staffing from quarantines and sickness, declining revenues as a result of people not going to the hospital for elective and non-elective care, and unexpected overtime and personal protective equipment (PPE) costs. One report in the Atlanta Journal-Constitution asserts that approximately 100 ambulance providers in the state sought paycheck protection loans from the federal government just to keep the wheels turning.4 The National Highway Transportation Association’s Office of EMS is deploying an “EMS COVID Resource Reporting Tool” for agencies to document their PPE needs and personnel shortages due to the pandemic.5 As this ambulance-oriented database matures–and when considered in conjunction with the IAFC data presented earlier–the information provided will allow for a more complete future assessment of the virus’ impact on prehospital staffing and, thereby, understand the broader implications for the American healthcare system.

One final note should be made about the IAFC’s statistics. These dashboards are based on voluntary reporting and are not a representative sample of departments. In fact, a minority of the departments are reporting. It is likely that these estimates undercount the true toll of COVID-19.

One example of how this will affect the broader healthcare system is found in the American Heart Association’s (AHA’s) Chain of Survival approach to cardiac events. The AHA has long recognized the benefit of quick access to quality CPR, rapid defibrillation, and fast access to advanced life support (ALS) as keys to survival of an out-of-hospital cardiac event.6 However, in many communities, quality CPR, early defibrillation, quick access to advanced life support, and rapid transport to definitive care come from these very firefighters and paramedics who have been furloughed and quarantined.

As an anecdotal example, some departments provide public training in bystander CPR to improve their community’s outcomes for out-of-hospital cardiac events. (My metropolitan Atlanta department does as part of the AHA’s Heart-Ready City initiative.) Due to COVID-19, many departments have closed their stations and suspended public education, including mass-CPR events. As the pandemic wears on, the side effects of this backwards step in community preparedness will only compound. Like the cascading effect of patients skipping oncology appointments during the pandemic–which has gotten a lot of attention in the national media and medical journals alike–delaying (or removing) the critical first links in the chain of survival will have a long-term negative effect on our otherwise improving cardiac event survival rates. Multiply this one example of cardiac arrest by the countless other rescues and EMS calls that rely on quick paramedic arrival, ALS care, and rapid transport to form the foundation of a successful medical outcome”¦to say nothing of responding to the COVID-19 cases themselves.

Traditional medical services–doctors, nurses, technicians and public health professionals in hospitals and medical office buildings across the nation–are clearly on the COVID-19 front line. However, prehospital providers are that critical first piece in the chain of survival and they have been significantly impacted by this pandemic. When compounded with the challenges to the hospital systems, this could form a downward trend of poor patient outcomes. In the coming months and years, there will be a significant conversation about how to improve the healthcare system and public health preparedness following this pandemic. This “after action analysis” needs to be collaborative, scientifically based, and non-partisan and involve all parts of the healthcare system — including the prehospital providers. EMS providers need to engage in these post-pandemic recovery conversations as they are taking place to ensure that field-level EMS has a seat at the table as we try to build back a more robust and resilient healthcare system.


1. IAFC. Covid 19 Fire & EMS Personnel Impact Dashboard. Retrieved from International Association of Fire Chiefs. August 11, 2020.

2. IAFC. IAFC COVID-19 Fire & Economic Impact Public Dashboard. Retrieved from International Association of Fire Chiefs. August 11, 2020.

3. U.S. Fire Administration. National Fire Department Registry Quick Facts. Retrieved May 25, 2020.

4. Berard, Y. Ambulance companies hit hard by COVID costs. Retrieved from Atlanta Journal Constitution. July 17, 2020.

5. National Highway Traffic Safety Administration. EMS COVID Resource Reporting Tool. Retrieved from the NHTSA’s National Emergency Medical Services’ Information System website. August 14, 2020.

6. AHA. Out-of-Hospital Chain of Survival. Retrieved from American Heart Association CPR & First Aid. Retrieved August 10, 2020.

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