Prehospital emergency department care activations during the initial COVID-19 pandemic surge




COVID-19, emergency departments, pandemic management, emergency medical services, resuscitation


Objective: To describe trends in prehospital presentations of critical medical and trauma conditions during the COVID-19 pandemic using prehospital and emergency department (ED) care activations.

Methods: Observational analysis of ED care activations in a tertiary, urban ED between March 10, 2020 and September 1, 2020 was compared to the same time periods in 2018 and 2019. ED care activations for critical medical conditions were classified based on clinical indication: undifferentiated medical, trauma, or stroke.

Main outcome: The primary outcomes were the number of patients presenting from the prehospital setting with specified ED activation criteria, total ED volume, ambulance arrival volume, and volume of COVID-19 hospital admissions. Locally weighted scatterplot smoothing curves were used to visually display our results.

Results: There were 1,461 undifferentiated medical activations, 905 stroke activations, and 1,478 trauma activations recorded, representing absolute decreases of 11.3, 28.1, and 20.3 percent, respectively, relative to the same period in 2019, coinciding with the declaration of a public health emergency in Connecticut. For all three types of presentation, post-peak spikes in activations were observed in early May, approximately two weeks after our health system in Connecticut reached its peak number of COVID-19 hospitalizations—eg, undifferentiated medical activations: increase in 280 percent, n = 140 from 2019, p < 0.0001—and declined thereafter, reaching a nadir in early June 2020.

Conclusions: After the announcement of public health measures to mitigate COVID-19, ED care activations declined in a large Northeast academic ED, followed by post-peak surges in activations as COVID- 19 cases decreased.

Author Biographies

Rebecca Leff, MD

Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota; Department of Emergency Medicine, Yale University, New Haven, Connecticut

Alex Fleming-Nouri, MBBS

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut

Arjun K. Venkatesh, MD, MBA, MHS

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut

Vivek Parwani, MD, MHA

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut

Craig Rothenberg, MPH

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut

Rohit B. Sangal, MD, MBA

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut

Colin T. Flood, MD, MBA

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut

Matthew Goldenberg, MD, MSc

Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Charles Wira, MD

Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut


Jeffery MM, D’Onofrio G, Paek H, et al.: Trends in emergency department visits and hospital admissions in health care systems in 5 states in the first months of the COVID-19 pandemic in the US. JAMA Intern Med. 2020; 180(10): 1328-1333.

Hartnett KP, Kite-Powell A, DeVies J, et al.: Impact of the COVID-19 pandemic on emergency department visits-United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(23): 699-704.

Tam CF, Cheung KS, Lam S, et al.: Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China. Circ Cardiovasc Qual Outcomes. 2020; 13(4): E006631.

Tarantini L, Navazio A, Cioffi G, et al.: Essere cardiologo ai tempi del SARS-COVID-19: è tempo di riconsiderare il nostro modo di lavorare? [Being a cardiologist at the time of SARS-COVID-19: Is it time to reconsider our way of working?]. G Ital Cardiol (Rome). 2020; 21(5): 354-357.

Markus HS, Brainin M: COVID-19 and stroke—A global world stroke organization perspective. Int J Stroke. 2020; 15(4): 361-364.

Garcia S, Albaghdadi MS, Meraj PM, et al.: Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol. 2020; 75(22): 2871-2872.

Rhodes HX, Petersen K, Biswas S: Trauma trends during the initial peak of the COVID-19 pandemic in the midst of lockdown: Experiences from a rural trauma center. Cureus. 2020; 12(8): E9811.

Lara-Reyna J, Yaeger KA, Rossitto CP, et al.: Staying home-early changes in patterns of neurotrauma in New York city during the COVID-19 pandemic. World Neurosurg. 2020; 143: e344-e350.

WTNH: Gov. Lamont declares civil preparedness, public health emergencies in response to coronavirus. What does that mean for you? Available at Accessed April 21, 2021.

Rosenbaum L: The untold toll—The pandemic’s effects on patients without COVID-19. N Engl J Med. 2020; 382(24): 2368-2371.

Raven MC, Lowe RA, Maselli J, et al.: Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA. 2013; 309(11): 1145-1153.

National Quality Forum: Advancing chief complaint-based quality measurement. Department of Health and Human Services. Available at Accessed April 21, 2021.

Cabañas JG, Williams JG, Gallagher JM, et al.: COVID-19 pandemic: The role of EMS physicians in a community response effort. Prehosp Emerg Care. 2021; 25(1): 8-15.

Mobile Heartbeat®: Our platform. Available at Accessed December 26, 2020.

Office of Governor Ned Lamont: Governor Lamont releases rules for businesses under first phase of Connecticut’s reopening plans amid COVID-19. Available at Accessed April 21, 2021.

Shekhar AC, Effiong A, Ruskin KJ, et al.: COVID-19 and the prehospital incidence of acute cardiovascular events (from the nationwide US EMS). Am J Cardiol. 2020; 134: 152-153.

Hsiao J, Sayles E, Antzoulatos E, et al.: Effect of COVID-19 on emergent stroke care: A regional experience. Stroke. 2020; 51(9): e2111-e2114.

Avila J, Long B, Holladay D, et al.: Thrombotic complications of COVID-19. Am J Emerg Med. 2021; 39: 213-218.

Sharma R, Kuohn LR, Weinberger DM, et al.: Excess cerebrovascular mortality in the United States during the COVID-19 pandemic. Stroke. 2021; 52(2): 563-572.

American Heart Association, American College of Cardiology, Association of Black Cardiologists, et al.: The new pandemic threat: People may die because they’re not calling 911. Available at Accessed April 21, 2021.

Zavadsky M: Complete April data shows alarming 911 trends for EMS calls during the COVID-19 pandemic. J Emerg Med Serv. Available at Accessed April 21, 2021.

Careless J: The calls that never came: 9-1-1 volume plunges with pandemic. EMS World. Available at Accessed April 21, 2021.

Al-Wathinani A, Hertelendy AJ, Alhurishi S, et al.: Increased emergency calls during the COVID-19 pandemic in Saudi Arabia: A national retrospective study. Healthcare (Basel). 2020; 9(1): 14.

Jensen T, Holgersen MG, Jespersen MS, et al.: Strategies to handle increased demand in the COVID-19 crisis: A coronavirus EMS support track and a web-based self-triage system. Prehosp Emerg Care. 2021; 25(1): 28-38.

Penverne Y, Jenvrin J, Montassier E: EMS dispatch center activity during the COVID-19 containment. Am J Emerg Med. 2021; 46: 654-655.

Prezant DJ, Lancet EA, Zeig-Owens R, et al.: System impacts of the COVID-19 pandemic on New York city’s emergency medical services. J Am Coll Emerg Physicians Open. 2020; 1(6): 1205-1213.

Salhi BA, White MH, Pitts SR, et al.: Homelessness and emergency medicine: Furthering the conversation. Acad Emerg Med. 2018; 25(5): 597-597.

Morris DM, Gordon JA: The role of the emergency department in the care of homeless and disadvantaged populations. Emerg Med Clin North Am. 2006; 24(4): 839-848.

Lerner EB, Maio RF, Garrison HG, et al.: Economic value of out-of-hospital emergency care: A structured literature review. Ann Emerg Med. 2006; 47(6): 515-524.

Lerner EB, Nichol G, Spaite DW, et al.: A comprehensive framework for determining the cost of an emergency medical services system. Ann Emerg Med. 2007; 49(3): 304-313.

Pedicelli A, Valente I, Pilato F, et al.: Stroke priorities during COVID-19 outbreak: Acting both fast and safe. J Stroke Cerebrovasc Dis. 2020; 29(8): 104922.

Agarwal G, Angeles R, Pirrie M, et al.: Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: A cluster randomized trial. CMAJ. 2018; 190(21): E638-E647.

Nolan MJ, Nolan KE, Sinha SK: Community paramedicine is growing in impact and potential. CMAJ. 2018; 190(21): E636-E637.

Iezzoni LI, Dorner SC, Ajayi T: Community paramedicine–addressing questions as programs expand. N Engl J Med. 2016; 374(12): 1107-1109.

Choi BY, Blumberg C, Williams K: Mobile integrated health care and community paramedicine: An emerging emergency medical services concept. Ann Emerg Med. 2016; 67(3): 361-366.

Pino R, Coler R: Legislative Report to the General Assembly: Regarding Mobile Integrated Health. Hartford, CT: Mobile Integrated Health Workgroup. Available at Accessed April 21, 2021.

National Association of Emergency Medical Technicians: Funding sources. Available at Accessed January 30, 2022.

Khosravani H, Rajendram P, Notario L, et al.: Protected code stroke: Hyperacute stroke management during the coronavirus disease 2019 (COVID-19) pandemic. Stroke. 2020; 51(6): 1891-1895.

Leasa D, Cameron P, Honarmand K, et al.: Knowledge translation tools to guide care of non-intubated patients with acute respiratory illness during the COVID-19 pandemic. Crit Care. 2021; 25(1): 22.

Center for EMS: Cardiac Arrest during COVID-19 Pandemic. New Haven, CT: Yale New Haven Health, 2020.

Kamine TH, Rembisz A, Barron RJ, et al.: Decrease in trauma admissions with COVID-19 pandemic. West J Emerg Med. 2020; 21(4): 819-822.

Staunton P, Gibbons JP, Keogh P, et al.: Regional trauma patterns during the COVID-19 pandemic. Surgeon. 2021; 19(2): e49-e52.

Nuñez JH, Sallent A, Lakhani K, et al.: Impact of the COVID-19 pandemic on an emergency traumatology service: Experience at a tertiary trauma centre in Spain. Injury. 2020; 51(7): 1414-1418.

Krösbacher A, Kaiser H, Holleis S, et al.: Evaluierung der maßnahmen zur reduktion von notarzteinsätzen in Tirol während der COVID-19-Pandemie [Evaluation of measures to reduce the number of emergency physician missions in tyrol during the COVID-19 pandemic. Anaesthesist. 2021; 70(8): 655-661.

Gosangi B, Park H, Thomas R, et al.: Exacerbation of physical intimate partner violence during COVID-19 pandemic. Radiology. 2021; 298(1): E38-E45.

Friedmann M, Dignan C, O’Leary M: In new haven, tensions rise in protest confrontation at police HQ. New Haven Register. Available at Accessed April 21, 2021.

Chan CC, Chuang KJ, Chen WJ, et al.: Increasing cardiopulmonary emergency visits by long-range transported Asian dust storms in Taiwan. Environ Res. 2008; 106(3): 393-400.

Five Thirty Eight: Normal America’ is not a small town of white people. Available at Accessed December 1, 2016.

Hart J, Tracy R, Johnston M, et al.: Recommendations for prehospital airway management in patients with suspected COVID-19 infection. West J Emerg Med. 2020; 21(4): 809-812.

Michigan Bureau of EMS, Trauma, and Preparedness: Michigan Emergency COVID-19 Pandemic Privileging and Participating Facilities Release during COVID-19 Response. Lansing, MI: Michigan Bureau of EMS, Trauma, and Preparedness. Report No.: 14-01. Available at Accessed April 21, 2021.

Gilboy N, Tanabe T, Travers D, et al.: Emergency severity index (ESI): A triage tool for emergency department care, Version 4. AHRQ Publication No. 12-0014. Rockville, MD: Agency for Healthcare Research and Quality, 2011.



How to Cite

Leff, MD, R., A. Fleming-Nouri, MBBS, A. K. Venkatesh, MD, MBA, MHS, V. Parwani, MD, MHA, C. Rothenberg, MPH, R. B. Sangal, MD, MBA, C. T. Flood, MD, MBA, M. Goldenberg, MD, MSc, and C. Wira, MD. “Prehospital Emergency Department Care Activations During the Initial COVID-19 Pandemic Surge”. American Journal of Disaster Medicine, vol. 17, no. 1, Mar. 2022, pp. 23-39, doi:10.5055/ajdm.2022.0417.




Most read articles by the same author(s)