Impact of COVID-Era Emergency Department Bypass Suspension on ST-Segment Elevation Myocardial Infarction System Performance in Rural Practice.
Critical pathways in cardiology · 2026-02-05 · Observational study
Abstract
BACKGROUND: During the COVID-19 pandemic, a temporary policy change required emergency medical services (EMS)-identified ST-segment elevation myocardial infarction (STEMI) patients to undergo COVID testing in the emergency department (ED) before percutaneous coronary intervention, suspending the standard ED bypass to the catheterization lab. We compared system performance metrics during this COVID-era routing to pre- and postpandemic periods in a large rural health system. METHODS: This was a retrospective single-center cohort study of consecutive EMS-identified STEMI activations across 3 periods: pre-COVID (May 27, 2018-March 26, 2020), COVID-era ED routing (March 27, 2020-January 25, 2022), and post-COVID with resumed ED bypass (January 26, 2022-November 26, 2023). Primary outcomes were standard STEMI system performance metrics; the secondary outcome was in-hospital mortality. RESULTS: A total of 373 patients were included (pre-COVID: 132; COVID: 104; post-COVID: 137). Compared to pre-COVID, the median time from EMS first medical contact to device time increased by 13 minutes ( P = 0.017). The median time from symptom onset to device time increased by 30 minutes ( P = 0.0013). The median time of first EMS electrocardiogram to device placement was increased by 14 minutes ( P = 0.013). The median door-to-device time was increased by 6 minutes ( P = 0.0007). There was a nonsignificant trend toward higher in-hospital mortality during the COVID era. CONCLUSIONS: In a rural STEMI system, pandemic-era routing of EMS-identified patients through the ED was associated with significant delays in key reperfusion metrics. While in-hospital mortality did not differ significantly, likely due to limited statistical power, these findings underscore the importance of preserving streamlined STEMI pathways. Larger multicenter studies to assess outcomes are warranted.