key: cord-0747103-bgu4x2xk
authors: Gutovitz, Scott; Pangia, Jonathan; Finer, Alexis; Rymer, Karen; Johnson, Dean
title: Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America
date: 2021-01-08
journal: J Emerg Med
DOI: 10.1016/j.jemermed.2021.01.002
sha: e0510498c874c35bcc2e93d6cab0c2e0835bd829
doc_id: 747103
cord_uid: bgu4x2xk

Background The COVID-19 pandemic precipitated fear of contagion and influenced many to avoid the Emergency Department (ED). It is unknown if this avoidance effected overall health or disease mortality. Objective We aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes. Methods We retrospectively accessed a multi-hospital, multi-state electronic health records database managed by HCA Healthcare to obtain a case series of all ED patients during the early COVID-19 pandemic (March 1st – May 31st, 2020), and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes. Results The weekly ED volume from 160 facilities dropped 44% from 141,408 patients (Week 1, March 1-7, 2020) to a nadir of 79,618 patients (Week 7, April 12-18, 2020), before rising back to 105,667 (Week 13, May 24-30, 2020). Compared to 2019, this overall decline was statistically significant, p<0.001. The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses. Conclusions The COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.

In late December 2019, a novel coronavirus pandemic (SARS-CoV-2) began in the 30 Wuhan province of China. Over the next several months, the viral disease called COVID-19 31 spread throughout China and began to spread internationally as well, first to Iran and Italy and 32 then subsequently to the United States. The first "hotspots" in the United States occurred in 33

Feb/March of 2020 on the West coast (California/Oregon/Washington), followed rapidly by the 34 New York City tri-state area. By April 2020, SARS-CoV-2 began spreading across the country. online. 1 After April 4 th , 2020, the CDC reported that a high volume of telemedicine visits 42 precluded them from gaining accurate data on ED visits for COVID-19-like illness or Influenza-43 like illnesses. However, the sharp decline in ED patient volume had many unanticipated 44 consequences, including decreased hours, furloughs, or terminations for many healthcare 45 workers (physicians and others). 2,3 46

In 2017, the most recent year complete data were available from the CDC, there were an 47 hospitals in the United States. Volume level ED data was abstracted from March 1st, 2019 76 through May 31st, 2020 for all adult (age > 18) patients seen in HCA Healthcare EDs. Safe 77

Harbor de-identification techniques were utilized such that no protected health information was 78 abstracted out of the central database for our analyses. The project received an institutional level 79 IRB exempt determination. We included all HCA Healthcare hospitals with EDs; and excluded 80 any hospital located outside of the USA, any hospital without an ED, and any hospital or ED 81 newly acquired by HCA Healthcare in 2020 which would not have comparison data from 2019. 82

For each ED in our dataset, we identified its location (state) and number of licensed hospital 83 inpatient beds as a proxy for hospital size. Precise ED size (bed count) was not available. Then 84 we calculated ED volumes on a weekly basis for each hospital during the early phase of the 85 COVID-19 pandemic (March 1st -May 30 th , 2020) and for comparison the corresponding weeks 86 in 2019. Final ED diagnosis codes were collected and collated by organ systems based on the 87 first letter of the ICD-10 codes. Other data abstracted from the database included the disposition 88 from the ED (admission, discharged, or expired), the highest level of inpatient floor required for 89 admitted patients (floor or intensive care unit (ICU)), the length of hospitalization (days), and the 90 final status (discharged home, to hospice, or expired). 91

Statistical analysis was performed using SAS 9.4 and graphs were created using Tableau 92 or Excel. Descriptive statistics were used to categorize hospital by size and location. We 93 compared ED volumes for all hospitals in the same weeks between 2019 and 2020 using 94 relationship of actual ED volume and mortality rate (number of deaths / actual ED volume). 99

This was done with and without including the infectious disease category, to account for any 100 COVID-19 related deaths. organ systems with the greatest increase in presentation to the ED were the infectious disease 120 were the infectious disease, circulatory, and respiratory categories. 122

After the nadir of ED volume in week 6-7, ED volume started to recover slowly towards 123 the expected volumes of 2019. For example, by week 10, the ED volume was at 64.9% of the 124 corresponding 2019 volume. In addition, all-cause mortality was declining by week 10 but was 125 still higher than the baseline value (week 1). This pattern continued until the end of the study 126

period, but neither all-cause mortality nor ED volume reached their respective baseline values. This study shows that the decreased ED patient volume during the early stages of the 149 COVID pandemic was associated with an increased number of deaths, actual numbers can be 150 seen in Figure 2 . Figure 3 shows three disease categories in which mortality rose during the 151 study period -infectious diseases, circulatory illness, and respiratory illnesses. Overall 152 mortality also increased during the study period. It is important to note that these mortality 153 increases occurred before these hospitals had more than minimal presence of SARS-CoV-2 in 154 the community as reflected by publicly reported SARS-CoV-2 testing results. 16, 17 Major 155 increases -a "spike" in cases -were not recorded in most southeastern or southwestern states 156 until June, 2020. As such, our observed increased mortality should not be attributed to 157 complications of SARS-CoV-2 infection. 158

There have been multiple reports in popular media 5-7 during this time that the general 159 population was afraid to go to their local hospitals due to the perceived risk of contracting 160 SARS-CoV-2 infection. For example, a survey of 1,000 telehealth patients in June, 2020, 161 revealed that only 12% of respondents felt an urgent care/ED was safe to enter compared with 162 42% finding a grocery store safe. 5 We did not attempt to discern the cause of the decreased ED 163 volumes in our study. We can only assert that the decreased ED volumes occurred several weeks 164 after the calendar "start" of the COVID-19 pandemic. However, given that the local SARS- Secondly, with this de-identified dataset we were only able to collect volume level data 202 on a weekly basis. No patient specific data -such as patient age, race, gender, or chief 203 complaint -was collected, thus limiting our results and analysis. It would have been interesting 204 to know which types of patients were less likely to present to the ED during this time period, 205 however this has been reported elsewhere by the CDC. 15 We arbitrarily set an end date for our 206 query of the database, knowing that this is a snapshot of the pandemic still occurring. However, 207 fear and hysteria were greatest in this time frame, and this would allow us to show the greatest 208 change in resultant ED volumes. It would be interesting to investigate how ED volume 209 recovered from June through the end of 2020 and beyond. 210

Lastly, we group patients into disease categories by using the first letter of the final ICD-211 treatment. Although it was a crude measurement, it did provide some useful information. For 213 ED patients that were discharged home, the primary final diagnosis code was used (no secondary 214 diagnosis codes). Similarly, for any admitted patients, only the primary final discharge diagnosis 215 code was used in this assessment. This system would introduce errors and missed diagnoses, 216 such as if they were sequenced incorrectly. It also caused some misclassification for our 217 analysis. For example, if a patient was diagnosed with "chest pain" (ICD-10 R07. 

National Syndromic Surveillance Program (NSSP): Emergency Department Visits 254 Percentage of Visits for COVID-19-Like Illness (CLI) or Influenza-like Illness (ILI)

Health care workers fear losing their jobs during coronavirus pandemic

Amid Pandemic, Hospitals Lay Off 1.4M Workers In

National Hospital Ambulatory Medical Care Survey

Delays in Stroke Onset to Hospital Arrival Time 299

During COVID-19

Impact of the COVID-19 Pandemic on

for Disease Control and Prevention, Coronavirus (COVID-19)

Coronavirus (COVID-19) Mortality Rate

The burden and severity of illness due to 312 2009 pandemic influenza A (H1N1) in a large US city during the late summer and early 313 fall of 2009

A survey of emergency department

Figure 2: Relative Weekly ED Volume & All-cause Mortality compared to Week 1

J o u r n a l P r e -p r o o f