Results

In Tamil Nadu, an Indian state the local emergency medical response system is
supported by the National Health Mission and managed by the government without
any charges to the public. People accessed Emergency medical services for various
causes of medical emergencies during the pandemic. The demand and utilization of
the local EMS varied based on the categories of emergencies. EMS received non-covid
calls predominantly related to Pregnancy, Acute Abdomen, Trauma (vehicular and
non-vehicular), cardiac/cardio vascular, respiratory morbidities in addition to Covid-
19 related calls during the pandemic. Hence, the authors chose to study the trends in
emergency care in these non-covid emergency categories during different phases of the
pandemic and also their impact on important clinical outcomes. The authors analysed
the utilization and the efficacy of the local EMS under three primary variables namely
call volumes with their diurnal variations, ambulance response time, victim handover
time and secondarily the time and distance covered by different types of ambulances
in various regions like urban, rural and metros. They focused on the pandemic period
analyzing the trends and patterns observed during each wave, post-wave and the
subsequent post-pandemic period. A comparative analysis was conducted by
comparing these metrics with the corresponding months from the pre-pandemic
phase. When the normal distribution assumption was violated, effect size was
calculated using the Cliff's delta measure and by Cohen's D otherwise. The authors
had undertaken a counterfactual analysis using the data of the pre-pandemic period
to arrive at predicted values of the above variables and also compared them against
the real time values.

Total call volume per day and the diurnal variation in the call timing

In Tamil Nadu, there was very negligible increase (4.44%, ES 0.17) in the total number
of daily calls to the Emergency Medical Services (EMS) system during the first COVID
wave. Post wave1, there was a slight drop in call volumes by 6.79% (ES -0.43).
However, the subsequent waves saw a substantial increase in call numbers especially
during wave2 and wave 3 with a significant rise of 26.72% (ES 0.76) and 22.67% (ES
0.83) respectively. Then on, the percentage change plateaued in the post pandemic
period (22.48%, ES 0.71). During the pandemic, the percentage increase in call
numbers were high during the daytime compared to night especially during wave 2
(36.31%, ES 0.78), and wave 3 (29.57%, ES 0.77) and continued similarly in post
pandemic (30.01%, ES 0.67) phase too.

Total call volume per day, response time and victim handover time based on the
emergency categories and clinical outcomes

During the wave1, there was no change in call volume regarding pregnancy related
emergency services (ES 0.17, 4.40%) 16), but the response time increased by 8.04%
(ES 0.4). However, the victim handover time decreased by 2.89% (ES -0.55). The
change in call volume was not significant during post wave1 and wave2. Subsequently
calls increased during post wave2 (20.40%, ES 0.71), wave3 (22.67%, ES 0.83) and the
post pandemic period (22.48%, ES 0.71). But then, time taken by the EMS to respond
to the calls gradually decreased from 22.5 minutes to 13.57 minutes reaching the
nadir change during post wave2 (ES -1.0) and wave 3 (ES -0.99) inspite of increased
call volumes in these phases. Similarly, the victim handing overtime was also lesser
during the pandemic witnessing peak changes causing most rapid handovers during
wave2 (ES -0.97) and post wave2 (ES -0.78). The reductions in these times were more
significant during the day compared to night services.

Maternal, Neonatal, Infant mortality rates are important clinical indicators of the
health services of that region. Maternal mortality increased by 26.3%/98.4%/53.7%
during first/second/third covid waves respectively and decreased by 12.96% in the
post pandemic period. Neonatal and Infant mortality rates rose higher than the pre-
pandemic in all the six phases, reaching the peak change of 11.37% in NMR during
wave2 and 8.64% in IMR post wave2. Women delivered at their own home maximum
by 66.26% more during post wave2 and percentages of home deliveries decreased
thereafter with lowest percentage change during wave3 (-24.48) and post-pandemic (-
21.04%) phases. Though Institutional deliveries decreased during the pandemic there
was an increase by 12.16% in the private sectors during first wave comparing with the
pre-pandemic period. Increase in cesarean births were maximum during the first wave
(10.5%) though smaller percentage increases were captured throughout the pandemic.
The changes in Miscarriages soared during the first and second waves by 14.75% and
13.01% respectively with decrease by 0.43% during the wave3.

There was a substantial decrease in vehicle/non-vehicular trauma calls by 141.85%

and 131.64%, ES -0.98/-1.0) respectively with negligible or slight increase in response
time (ES 0.11/0.31 respectively) and a significant decrease in victim handover time
(ES -0.72/-0.49, -10.29%/-9.03%, respectively) during wave1. During wave2, although
the calls decreased only minimally (ES -0.24) there was a remarkable reduction in
response time (ES -0.95/-0.91 respectively) and victim handover time (ES -0.71/-0.49
respectively). The Post wave2 and wave3 saw an increase in call volume and a
continued significant reduction in response time. However, EMS took longer time to
handover patients in the hospital during the wave3 (ES 0.76, 8.81%) and post-
pandemic phases (ES 0.87, 10.99%).

The number of patients calling EMS for acute abdomen/ Cardiac and Cardio
Vascular/ Respiratory complaints significantly decreased during wave1 by 130.92%
(ES -1.0)/-104.47%, (ES -1.0)/ 68.39% (ES -0.74) and also post wave1 (50.25%, ES -
0.79)/29.67% (ES -0.67)/20.08% (ES -0.37) respectively. The trend continued during
wave2 also except for slight increase in respiratory calls (20.44, ES 0.3). As the
pandemic moved through the next phases (post wave2/wave3/post pandemic) call
volumes started scaling up in all these categories significantly. Regarding the response
time, though EMS took longer time to respond to all these category calls during wave1,
in subsequent phases there was a significant decrement and this trend continued even
post pandemic. Patients with complaints related to acute abdomen/ Cardiac and
Cardio Vascular and Respiratory complaints were handed over faster than the pre-
pandemic period in the initial phases of the pandemic. But the handing over time
started increasing after the second wave with maximum percentage change observed
during the wave3 and post pandemic phases.
Comparing the volume of covid calls during the wave1/wave2/wave3, EMS
encountered 1240/578/130 median number of calls each day. The response time of
EMS decreased gradually through the span of the pandemic from almost 15.5 minutes
during wave1, to 9.6 minutes during wave2 and to 7.4 minutes during wave3. The
authors saw an increasing trend in the patient handing over time as the state sailed
through the successive phases of the pandemic. EMS took 13/15/17 minutes during
wave1/wave2/wave 3 respectively to handover the patients. The maximum duration
was spotted during the post pandemic phase (24.5 minutes). Ambulances took a mean
time of 126.99/121.72/130.04 minutes to cover a mean distance of kilometers
56.49/53.61/54 during wave1/wave2/wave3 of the pandemic respectively. The mean
duration was the same during pre-pandemic (132.58 minutes) and post pandemic
periods (130.37 minutes) regardless of the type. Ambulances operating in the metro
localities covered shorter distances (23.88 kilometers) in lesser times (105.58 minutes)
compared to ones operated in the rural as well as urban regions of the state.

Thus, the research team observed an overall increase in the call volumes, decrease in
the response time and an increase in the patient handing over time related to non-
covid emergencies such as pregnancy, trauma both vehicular and non-vehicular,
acute abdomen, respiratory, cardiac and cardiovascular ailments, respiratory
morbidities after the second wave of Covid-19 pandemic without much diurnal

variations in their trends as the covid related calls relatively decreased .

Discussion

COVID-19 pandemic is a public health emergency of international concern. It

posed new challenges and strain on the local emergency medical services throughout
the globe as they served as the major accessible transport system to the patients to
reach health care facilities for all medical emergencies. Globally EMS suffered
handling huge increase in call volumes and their operational efficacy declined due to
limited resources throughout the Pandemic. During wave1in TN, there was only a
slight increase in the total number of daily calls to the EMS which were predominantly
covid related and there was even a slight drop in call volumes during Post wave1
unlike other countries. The first wave of covid in these countries occurred much
earlier than India and especially Tamil Nadu, showcasing rapid spread of infection
among contacts and high mortality among infected. This immensely increased the fear
among Indian patients and deterred them from reaching out to health care services for
their ailments especially non-covid related disorders such as pregnancy, trauma,
acute abdomen, respiratory, cardiac/cardiovascular and respiratory morbidities
similar to regions like Massachusetts (Goldberg and others, 2021).
 But this fearful procrastination did not last long. Extensive health education and
campaigning to utilize the local EMS Dial 108 by the State Government and health
sectors, allayed the anxiety and enabled patients to seek health care for these time
sensitive disorders in the subsequent phases of the pandemic. This is evident from the
explicit data showing huge increases in calls for the non-covid emergencies
subsequently in postwave2, wave3 and post pandemic phases.

The unprecedented overload strained the EMS system’s capacity increasing

ambulance response time in many countries, the major reason being resource
limitation in number of ambulances, HCW, PPE and sanitation kits to meet the
unexpected demand. (Bekgöz and others, 2022). In TN, though there was an increase in the
response time initially during wave1, it reduced steadily through all subsequent
phases of the pandemic for both covid and non-covid emergencies. This was mainly
possible by the excellent measures and successful strategies adopted and undertaken
by the State and Central Governments. Government mobilized more ambulances,
allocated more health care workers for EMS, provided PPEs and sanitation kits
matching the demand and provided incentives to HCWs who worked for EMS. These
strategies provided more ambulances to attend to patient transportation and also
motivated and prevented EMS personnel contracting infection during transport. The
stakeholders allocated funds liberally from the budget to provide these resources and
also sought and utilized the help from the non-Governmental organisations.

Government adopted strategies for triaging covid patients who were given
appropriate care in the hospitals designated for covid management. Most of the
tertiary health care centers both in the public and private sectors were designated for
managing covid patients and received financial supports from the Government to step
up facilities for patient management. These centers created dedicated space, HCW and
resources to manage covid patients and rising numbers of non-covid patients
separately in the wave2, post wave2 and wave3. HCW were encouraged to work in
these hospitals through incentives during pandemic period. Such timely mobilization
of the human and non- human resources expedited the patient handing over time and
released ambulances earlier to respond to the next call. But as the covid severity and
numbers decreased subsequently, withdrawal of these strategies and resumption of
public mobility after lockdowns witnessed increased patient handover times under all
the emergency categories in the post pandemic period except maternity care which is
even otherwise ably supported by the maternal and child health programs of the
government. (Obstetrics and Neonatal Outcomes in Pregnant Women with COVID-19: A

Systematic Review, 2020) .

Throughout the world even in developed countries with state of art health care
facilities Maternal mortality increased during the Pandemic (40% in US). () In Tamil
Nadu, one of the states with lowest Maternal, Neonatal, Infant mortalities in the pre-
pandemic period, the percentage hike during pandemic seems low relatively comparing
with other developing countries. () TN state with the support from the National health
Mission has a well-established health care system. Early diagnosis through universal
screening of all antenatal mothers, mass health campaigns to change the health
seeking behaviors of the people to utilize the EMS during the lockdown and reach
health facility for better care probably resulted in relatively lesser climb in the
mortalities. The authors did observe this from increased home deliveries in the initial
phase and then numbers declining subsequently. Many health centers opted to deliver
mothers by cesarean section to prevent bad outcomes and due to fear of exposure
during prolonged hours of monitoring during vaginal delivery compared to elective
cesarean deliveries which is displayed by the hike in Cesarean deliveries and drop in
complicated vaginal deliveries.