The Calls That Never Came: 9-1-1 Volume Plunges With Pandemic

It seems hard to believe, but it’s true: The onslaught of COVID-19 in March 2020 led to a drop in EMS calls for many agencies across America.

Two EMS agencies that experienced this drop were Montgomery County (Md.) Fire & Rescue and the ambulance service operated by Cascade Medical, a nonprofit critical access hospital in Leavenworth, Wash. Both expected surges in patients with COVID, only to see EMS calls unexpectedly fall—and revenues plunge along with them.

A Substantial Drop

The numbers tell the tale: The rural Eastern Washington region served by Cascade Medical normally has about 1,200 EMS calls a year. “After the stay-at-home order was issued in March by Gov. [Jay] Inslee, our numbers were down 30% right off the bat,” says Pat Songer, Cascade Medical’s COO. EMS calls weren’t alone in being affected: “Our rural clinic volume was down 50%, and our emergency department was down 35%,” he adds.

The same was true for the Montgomery County, whose department serves about one million people north of Washington, D.C. The drop in EMS calls “was like turning off a faucet,” says Capt. Tim Burns, who heads MCFRS’ quality improvement office and tracks such data in detail. “Prior to the stay-at-home order, we were at about 1,500 EMS patients a week. Afterward it dropped to 1,000.”

Call volumes for both organizations remained low into April, at a time when COVID-19 infections were climbing in their jurisdictions.

So what happened? Patients who would have normally called EMS for help were staying at home. They were more frightened of the perceived pandemic dangers associated with riding in ambulances and going to hospitals than the actual medical emergencies that would normally compel them to call 9-1-1.

To be precise, “Folks weren’t going to the hospital for run-of-the-mill stuff, but they were calling us when they were truly, truly ill,” says Burns. “So from the middle of March to the beginning of May, Montgomery County saw a serious uptick in the number of seriously ill Priority 1 patients, while the less ill Priority 3s went down.”

Cascade experienced the same trend: “People were only calling when they were really, really sick or a trauma had occurred, rather than the usual mix of noncritical and critical EMS calls,” Songer says. “Even today people are still reluctant to be transported to hospitals if they think they can avoid it, thanks to COVID-19.”

Tough on Crews

The trend toward “lower EMS calls with higher acuity,” as Burns describes the period between mid-March and early May, was tough on EMS crews for many reasons.

For one thing, wearing PPE during much or all of their shifts was uncomfortable and tiring, as was the need to heighten sanitization and other infection-deterrence routines. For another, treating a much higher percentage of serious/critical patients was physically and emotionally taxing compared to the normal mix of high- and low-pressure cases EMS would face during a prepandemic shift. It was like exchanging a marathon for a series of sprints.

“We were spending much more time at nursing homes, and the number of cardiac arrest resuscitations went way up,” says Burns. “We were doing 4–5 resuscitations in nursing homes a day and nine countywide, compared to the one a day at nursing homes and three countywide our people were accustomed to.

“You can imagine just how exhausting it was for our people to do so many resuscitations and deal with really sick patients on a daily basis. But this exhaustion wasn’t just physical—it was emotional and mental as well.”

If this weren’t enough stress for EMS crews to cope with, the drop in calls kept them sitting around waiting for action, only to be plunged into high-stakes drama when the tones did sound. The situation was reminiscent of how a soldier’s life during war has been described: Periods of boredom punctuated by moments of terror.

Add the fears that EMS personnel had for their own families and friends at home, plus the need to self-isolate to keep their loved ones safe and the indefinite nature of the pandemic, and it’s no wonder they were stressed then—and continue to be today.

Fewer calls also means lower revenues for EMS agencies. This is never good news, but it was particularly bad when agencies had added shifts and extra equipment to cope with an expected call increase.

The silver lining to this cloud? At Cascade Medical, “The drop in calls is somewhat offset by the higher acuity, which results in more services being billed at a high level in the emergency department,” says Songer. Meanwhile, the MCFRS’s budget “is independent of the revenue we collect from patient billing, so it wouldn’t immediately reflect changes in the amount we’re collecting.”

The only downside is that any serious reduction in the county’s tax revenues due to COVID-19 could be reflected in future budget cuts. The same risk applies to taxpayer-supported Cascade Medical as well. They may not be feeling the pain now, but they may later.

Where They Stand Now

Looking back at the COVID-19 crisis, both Songer and Burns remain surprised at how much EMS calls dropped once the lockdown set in. At the time this article was written, calls hadn’t returned to prepandemic levels, but the ongoing relaxation of lockdown rules, combined with the public’s familiarity with COVID-19, was helping to boost call volumes.

“The way things are going, something close to normal could occur when the kids go back to school in September, assuming that this proves to be the case,” says Burns. “Calls tend to go up once school resumes and vacationers return to work.”

“In the meantime, the biggest lesson we’ve learned is to be very agile in the face of crisis,” adds Songer. “When things are changing every day, as happened with COVID-19, you have to be prepared to change with them—including when reality doesn’t match your expectations.”

James Careless is a freelance writer and frequent contributor to EMS World.