The COVID-19 pandemic has shaken U.S. society in a way that few public health crises have, with many drawing comparisons to the AIDS epidemic or the 1918 Flu pandemic. One of the states hit earliest and hardest was New Jersey, which saw its first diagnosed case on March 4th, 2020.1 The situation escalated rapidly; by early April, there had been nearly 40,000 cases diagnosed in New Jersey and nearly 1,000 confirmed COVID deaths, with many more presumably unaccounted for at the time.1 Hospitals filled, case numbers spiked, and the death toll continued to rise, causing fundamental shifts throughout the healthcare system.
Some ambulance organizations were unable to take COVID calls as they lacked the personal protective equipment (PPE) to safely respond to them.2, 3 New Jersey hospitals also allowed physicians to issue do not resuscitate orders – albeit after extremely careful consideration – on COVID-positive patients whose odds of survival were minimal.4 Similar steps were taken by New York EMS clinicians when the NYS Health Department instructed ALS members not to attempt resuscitation on pulseless patients, however this order was quickly rescinded.5 As a result of these policies experienced EMTs, witnessed veterans of the healthcare field break down in tears unable to cope with the sheer volume of death they were facing.
- How Empress EMS (NY) Responded to COVID-19 in the Pandemic’s Epicenter
- Regions Hospital (MN) Community Paramedic Response to COVID-19
- Applying an Asymmetric Solution to an Asymmetric Problem
This introduction serves to illustrate that the COVID-19 pandemic forced EMS clinicians to adjust how we delivered patient care and make decisions in ways that many of us never imagined we would have to. This was true for workers at all levels of care, but EMS clinicians had their own unique issue to grapple with: deciding when to transport a patient.
Admittedly, the term “deciding to transport a patient,” is somewhat misleading. Under normal circumstances, New Jersey EMS clinicians do not decide whether a patient is transported or not. Before the COVID-19 pandemic, EMS clinicians could not legally refuse to transport a patient requesting to be taken to a hospital, unless doing so required them to physically endanger themselves (ex. If the patient is violent).6
There are many times where EMS will transport a patient to a hospital who ends up not needing emergency care. Under normal circumstances, comparing the potential cost of refusing care to the cost of a hospital visit, the risk-benefit analysis favors transport, with the potential costs being the hospital bill and the risk for hospital acquired infection. These costs are legitimately burdensome, but when weighed against the risk of an emergent life threat the decision to transport is ultimately favored. However, this straightforward-decision making only works in a “normal” situation, where the health risks of transport are usually low relative to the risks of not seeking medical care.
During the COVID-19 pandemic, there were additional considerations which made reducing unnecessary transports imperative. EMTs now had to contend with potentially overcrowded hospitals, transporting a COVID-positive patient that could infect other patients at the hospital, and exposing COVID-negative patients to COVID-positive patients in waiting rooms or via contact with hospital staff. This put EMTs in a position of explaining the risks of transport to a patient and making a recommendation to them that many felt unprepared to make with the tools available to them.
For example, a patient who is experiencing symptoms consistent with acute coronary syndrome presents EMS clinicians with a difficult challenge. Even with the tools available to ALS clinicians such as an electrocardiogram, it may be impossible to distinguish whether the patient is suffering from something relatively benign such as acid reflux or a non-ST segment elevated myocardial infarction a life-threatening condition. Under normal circumstances, EMS clinicians would likely recommend that the patient be transported to the hospital for further diagnostic testing and observation. However, during the COVID-19 pandemic, that patient may have had to sit in a waiting room surrounded by infectious COVID patients, potentially leading to infection.
If EMS encourages the patient to seek care, they may be exposing them to infection (or, if the patient is already infected with coronavirus, bringing another infectious individual into the hospital system) and raising the burden on the healthcare system, potentially for a minor issue. However, allowing a patient to forgo transport, under the duress of the pandemic, meant accepting the risk that the patient is experiencing a potentially fatal medical emergency which would remain untreated.
In both situations, EMS clinicians’ decisions pose a real and present danger to the patient’s health and life—a burden these clinicians are ill-equipped to carry. This issue holds especially true for members of smaller EMS organizations, particularly volunteer agencies, who often operate with only one physician medical director, leaving them without access to a team of physicians that can help guide care provision. This issue became significant enough that the State of New Jersey ultimately chose to step in.
In an attempt to help with the burden on the hospital system and reduce the number of infectious individuals in hospitals, New Jersey implemented a novel protocol allowing EMS to triage potential COVID patients whose symptoms met specific criteria (judging them to be low-risk) to home. The initial version of this protocol released on April 1st was both groundbreaking and controversial in that it provided EMS clinicians the authorization to triage patients to home based on pre-established criteria.
To do this, EMS clinicians would first establish that the patient met criteria for triage to home, as described,6 which indicated that the patient was low-risk. Clinicians would then contact their physician medical director or New Jersey Poison Control (NJPIES) to confirm this decision with a physician or a nurse. If they were unable to reach these designated medical authorities, EMS clinicians could then autonomously choose to triage the patient to home. Two weeks later, this statewide policy was amended to require EMS clinicians to consult with their previously specified organizational medical direction prior to triaging a patient to home.7
This meant that EMTs could no longer triage a patient to home without directly talking to a physician nor could they seek direction from state or hospital physicians. This was problematic for smaller organizations and volunteer ambulance corps, many of which only have one physician capable of providing medical direction, and this physician may also serve in a clinical capacity and is therefore not always reachable. Thus, while the policy was ultimately helpful even in its altered state, its efficacy was limited in many circumstances.
Regardless, the state protocols gave EMS clinicians an incredibly valuable tool: a clear set of criteria to help them identify who should be transported to the hospital at a time when hospitals were potentially overwhelmed and unnecessary transport posed great risks to all involved. Unfortunately, the final version of this criteria made it so that it was significantly underutilized, particularly in smaller organizations. Perhaps more significantly, these protocols were also limited to COVID patients, providing no guidance for EMS in dealing with patients with non-COVID-related conditions.
In these situations, when the severity of the patient’s condition was ambiguous, EMS clinicians were still left in a complicated position, struggling due to the potentially life-threatening consequences to the patient. It is also important to note that although EMS could not refuse transport to a patient except in the circumstances described above, many patients look to EMS for recommendation on whether to opt for or forgo transport, and thus, the decision to transport is to some extent oftentimes left up to EMS.
What we ultimately hope to illustrate with this brief history is that EMS clinicians are ill-equipped to perform a reasonable risk assessment when it comes to patient transport during a pandemic, and asking them to do so without proper protocols leaves patients open for significant risk. EMS clinicians performed to the best of their abilities, just as all EMS clinicians did, providing their patients with as accurate an explanation of the risks associated with transport versus remaining at home and encouraging patients to make their own decisions based on that information. For many, the lack of resources and guidance was at times overwhelming, when added to the stress of unprecedented levels of death and disease seen during the peak of COVID.
All organizations have been adapting to the best of their ability, acting appropriately and in good faith, throughout the duration of this pandemic. We do, believe that it is important to recognize the challenges faced by those in the healthcare field, and the aspects of the healthcare system that have been exposed by the COVID-19 pandemic and that may be adjusted in order to help overcome these challenges or at least mitigate the stresses experienced by those who face them. With multiple U.S. Food and Drug Administration (FDA) emergency use authorized vaccines, there is hope that this pandemic may soon be behind us.
While we hope that a crisis such as the COVID-19 pandemic will not arise in the future, it would be unwise not to prepare for this possibility. We should therefore take this opportunity to learn from this tragedy and improve upon the weaknesses it has revealed in our current system. Other states and organizations have either implemented or proposed their own triage to home protocols. The only protocol guiding transport decisions for non-COVID patients which we were able to find was suggested by the National Association of State EMS Officials (NASEMSO).
This algorithm proposed in April of 2020, suggested that EMS seek medical direction on whether to transport for non-critical patients, or transport to non-hospital care facilities such as urgent care centers.8 While the NASEMSO guidelines are admittedly nonspecific and do not outline off-line directions in the event that an organization’s physician medical director cannot be reached, they do provide a reasonable starting point from which future protocols can be developed. We hope that by developing such protocols for the future it is possible to improve the care delivered to patients, and alleviate the burden placed on EMS clinicians during times of crisis.
- Fallon, S., 2020. Coronavirus in New Jersey: A timeline of events from first cases to the first vaccination. [online] Northjersey.com. Available at: <https://www.northjersey.com/story/news/health/2020/03/10/coronavirus-new-jersey-timeline-events-covid-covid-19/4964918002/> [Accessed 11 February 2021].
- Kanzler, K., 2020. Cedar Grove ambulance squad won’t respond to emergencies during coronavirus crisis. [online] NorthJersey.com. Available at: <https://www.northjersey.com/story/news/essex/verona-cedar-grove/2020/03/31/coronavirus-cedar-grove-ambulance-squad-wont-respond-emergencies/5098323002/> [Accessed 11 February 2021].
- Sargeant, K., 2020. After the deaths of 13 EMS workers, coronavirus is forcing some N.J. squads to drop service. [online] nj. Available at: <https://www.nj.com/coronavirus/2020/04/after-the-deaths-of-13-ems-workers-coronavirus-is-forcing-some-nj-squads-to-drop-service.html> [Accessed 11 February 2021].
- Sargeant, K., 2020. N.J. hospitals consider do-not-resuscitate orders for coronavirus patients to protect doctors, nurses. [online] nj. Available at: <https://www.nj.com/coronavirus/2020/04/nj-hospitals-consider-do-not-resuscitate-orders-for-coronavirus-patients-to-protect-doctors-nurses.html> [Accessed 11 February 2021].
- Herbert, G., 2021. NY rescinds new resuscitation guidelines for EMS. [online] EMS1. Available at: <https://www.ems1.com/resuscitation/articles/ny-rescinds-new-resuscitation-guidelines-for-ems-jTislkdO8t4oslEZ/> [Accessed 11 February 2021].
- New Jersey State Department of Health, 2020. Notice of Rule Waiver/Modification Pursuant Executive Order No. 103. Trenton: New Jersey State Health Department.
- New Jersey State Department of Health, 2020. Notice of Rule Waiver/Modification Pursuant Executive Order No. 103 and Executive Order No. 119. Trenton: New Jersey State Health Department.
- NASEMSO, 2020. Guidelines for EMS During COVID-19 Pandemic Transports to Non-Traditional Destinations. [online] Available at: <https://nasemso.org/wp-content/uploads/EMS_Alternate_Transport_Algorithms-IL.pdf> [Accessed 11 February 2021].