COVID-Era EMS Refusals Rose, Study Finds
When COVID-19 struck in spring 2020, many EMS systems reported lower call volumes and more patients reluctant to go to the hospital. A new study suggests that hesitation showed up in EMS transport decisions, with refusal of EMS-recommended transport increasing during the early pandemic period.
The study is named “Impact of the COVID-19 Pandemic on Patients’ Refusal of Emergency Medical Services (EMS) Transport.” It was published in March 2026.
EMS World spoke with two of the study’s authors to learn more. Because the study examined one ground ambulance service, the authors cautioned that the findings may not reflect every EMS system. But they do provide a focused look at early-pandemic refusal behavior.
Dr. Bradley M. Golden is Associate Professor of Emergency Medicine and EMS Fellowship Program Director at the Medical College of Georgia at Augusta University.
Dr. Vijay A. Reddy is Assistant Professor of Emergency Medicine and EMS Fellowship Assistant Program Director at the Medical College of Georgia at Augusta University.
EMS WORLD: Could you describe the objective, methodology, motivation behind the research, and your primary findings?
DR. BRADLEY M. GOLDEN: The objective of our study was to evaluate whether the COVID-19 pandemic influenced patients’ decisions to refuse EMS evaluation or transport to the hospital.
Early in the pandemic, many EMS systems and emergency departments across the United States reported significant declines in patient volumes despite ongoing medical emergencies. We wanted to better understand whether fear, uncertainty, or behavioral changes associated with the pandemic were contributing to increased refusal rates in the prehospital setting.
EMS WORLD: How did you research this?
DR. VIJAY A. REDDY: We performed a retrospective observational study using EMS run report data from a single ground ambulance service in North Augusta, South Carolina. We compared two 90-day periods: March 13 through June 11, 2019, and the same period in 2020, beginning with the U.S. national emergency declaration for COVID-19. Encounters were categorized based on whether patients accepted transport, refused evaluation, or refused EMS-recommended transport after evaluation.
EMS WORLD: What did you learn?
GOLDEN: Our primary finding was that refusal of EMS-recommended transport increased significantly during the early pandemic period, rising from 5.7% in 2019 to 8.7% in 2020.
Additionally, the combined proportion of patients refusing evaluation or refusing recommended transport increased from 16.5% to 19.1%.
We also observed that the proportion of emergent 9-1-1 calls increased during the pandemic despite an overall decrease in total call volume.
EMS WORLD: Given the circumstances of the pandemic, were you surprised that refusal rates weren’t higher?
REDDY: Yes and no. We certainly expected refusal rates to increase because of the intense public concern surrounding COVID-19 exposure, particularly early in the pandemic when information was evolving rapidly and hospital visitation restrictions were widespread. However, we were somewhat surprised the increase was not even greater given the level of fear and uncertainty during that time.
EMS WORLD: Why do you think refusal rates weren't higher?
GOLDEN: One possible explanation is that patients who activated 9-1-1 still generally perceived their condition as serious enough to warrant medical attention despite concerns about the healthcare system. EMS providers also play a critical role in patient counseling and risk communication on scene, which may have helped some patients ultimately agree to transport despite initial hesitation.
At the same time, even relatively modest percentage increases in refusals can represent meaningful operational and public health concerns, particularly when serious illness may be present.
EMS WORLD: Were you able to determine the specific reasons for these refusals?
REDDY: No. One of the primary limitations of our study was that we did not have detailed patient-level qualitative data explaining why individual patients refused evaluation or transport.
However, based on broader healthcare trends and published literature during the pandemic, it is reasonable to believe that fear of COVID-19 exposure, concern about hospital overcrowding, uncertainty regarding visitation policies, financial concerns, and misinformation may all have contributed to refusal behavior.
Future studies incorporating patient interviews, demographic analysis, and follow-up outcomes would help better clarify the specific motivations behind these decisions.
EMS WORLD: What do you hope can be learned from your study for application to future pandemic events?
GOLDEN: We hope this study highlights the importance of clear public communication during public health emergencies. Patients need reassurance that emergency medical care remains safe, accessible, and appropriate even during pandemics or disaster situations.
REDDY: We also believe the study reinforces the critical role EMS providers serve not only as emergency clinicians, but also as trusted communicators and public health ambassadors within the community. EMS personnel are often the first healthcare professionals patients encounter during crises, and their ability to educate, reassure, and counsel patients may directly influence care decisions.
GOLDEN: Finally, understanding refusal trends may help EMS systems and hospitals better prepare operationally for future pandemics or large-scale public health emergencies by improving patient education strategies, provider training, and follow-up systems for high-risk refusals.
REDDY: Future pandemic planning should also consider the expansion of alternative treatment destinations, mobile integrated healthcare programs, and community paramedicine models that can safely connect patients with appropriate levels of care outside the traditional emergency department setting when clinically appropriate. Additionally, broader public health efforts focused on accurate messaging, healthcare access, and strengthening primary care infrastructure may help reduce fear-driven avoidance of necessary medical care during future public health crises.
