key: cord-0799331-dwy160jr
authors: Steinman, Milton; de Sousa, Jorge Henrique Bento; Tustumi, Francisco; Wolosker, Nelson
title: The burden of the pandemic on the non-SARS-CoV-2 emergencies: A multicenter study
date: 2021-01-01
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.12.080
sha: bda4d93fc1c523bbfa1512ede4160e67df6014ee
doc_id: 799331
cord_uid: dwy160jr

BACKGROUND: Governments have implemented social distancing interventions to curb the speed of SARS-CoV-2 spread and avoid hospital overload. SARS-CoV-2 social distancing interventions have modified several aspects of society, leading to a change in the emergency medical visit profile. OBJECTIVE: To analyze the impact of COVID-19 and the resulting changes on the non-SARS-CoV-2 emergency medical care system profile. METHODS: This is a retrospective multicenter cross-sectional study evaluating medical consultations, urgent hospitalizations, and deaths in São Paulo, the largest city of the Americas. Changes in the medical visit profile according to demographic data and diagnoses were assessed. The change in mortality was also assessed. RESULTS: A total of 462,412 emergency medical visits were registered from January 2019 to July 2020. Of these emergency medical visits, only 4.7% (21,653) required hospitalization. Of all visits, 592 resulted in deaths, equivalent to 0.1% of the sample. There was a clear decreasing trend in the number of weekly emergency medical visits as social distancing was mandated by decree (Coef. -3733.13; 95% CI −4579.85 to −2886.42; p < 0.001). The number of medical visits for conditions such as trauma, abdominal pain, chest pain, and the common cold decreased (p<0.05). However, the number of medical visits for the following conditions did not change after the onset of the pandemic (p≥0.05): ureterolithiasis, acute appendicitis, acute cholecystitis, acute myocardial infarction, and stroke. CONCLUSION: The COVID-19 pandemic has changed the non-SARS-CoV-2 emergency profile. The overall number of emergency medical visits has reduced. The mortality of non-SARS-CoV-2 emergencies has not increased in São Paulo.

Knowing the changes in emergency health-care system patterns allows authorities to direct health-resource allocation. This study aims to analyze the impact of the COVID-19 and the resulting changes on the non-SARS-CoV-2 emergency profile. All patients of the emergency care units were included. All patients were evaluated by physicians. In this observational study, the exposition was the social distancing period, and the outcome variable was the number of medical visits. Thus, the change in the number and profile of emergency visits across months in the 2019-2020 period according to sex, age, specialty, and diagnosis were assessed, and a comparison was made before and after the social distancing decree (March 22, 2020). The Albert

Einstein Ethics Committee approved this study (CAAE: 32353120.2.0000.0071).

STROBE statement was followed for reporting [9] .

J o u r n a l P r e -p r o o f Journal Pre-proof Continuous variables were described by means and standard deviations or medians and interquartile ranges. Categorical variables were shown as relative and absolute frequencies. Comparisons between continuous variables were performed using the Mann-Whitney test.

All hospitals included in this study use a common medical chart system in which all clinical data are prospectively inserted. An epidemiologist abstracted the variables of interest. The data were transferred to a computed database for subsequent statistical analysis. The epidemiologist was blinded to the study hypothesis. 

A total of 462,412 emergency medical visits were registered from January 2019 to July 2020. All medical visits of the emergency care units with non-SARS-CoV-2 related conditions were included, and charts for 4,248 (<1%) visits were missing information concerning the outcome "death or discharge". These were excluded only from analysis of this outcome. No other exclusion criteria were adopted. No other exclusion criteria were adopted. 4.7% (21,653) of patients were hospitalized. Of all visits, 592 resulted in deaths, equivalent to 0.1% of the sample (see Fig. 1 ). In the J o u r n a l P r e -p r o o f Journal Pre-proof casuistry, there was a slight female predominance (58%). The majority of the patients were children and adolescents (<16 years-old), or adults (<45 years-old). The main emergency department consultations were directed to general practitioners (52%); pediatrics (27%); and surgeons (25%). The baseline characteristics of the patients are shown in Table 1 

These multicenter study results show that the number of emergency visits for most non-SARS-CoV-2-related conditions was greatly reduced. However, this was not the case for some nontraumatic surgical emergencies and cardiovascular emergencies.

Fortunately, the mortality of non-SARS-CoV-2 emergencies has not significantly increased after pandemic onset and the social distancing decree in São Paulo.

One of the biggest fears of the SARS-CoV-2 pandemic was that COVID-19 would rapidly increase mortality due to non-SARS-CoV-2 emergencies with the collapse of health services due to COVID-19 [10] . The dramatic change in the emergency medical visit profile probably helped in some way to avoid an expressive increase in the mortality of non-SARS-CoV-2 emergencies.

The intense reduction in traffic probably changed the trauma emergency service profile, explaining the large reduction in traumatic injuries. Land-based transport accidents are quite relevant in São Paulo due to heavy traffic and many motorcycles [11, 12] . Many trauma-related injuries are caused by car crashes, motorbike accidents, accidents involving pedestrians, or bicycle accidents [12] . Consequently, the reduced traffic density may have affected the number of these accidents.

Additionally, it is well known that several types of interpersonal violence occur in streets. The end of parties, the closure of pubs and bars, and the comprehensive ban of large gatherings may have helped reduce these causes of trauma [13] . On the other hand, restrictive measures may have changed the victim profile. The home confinement orders left many victims trapped with their aggressors. Domestic violence increased during the pandemics [14] . Restrictive measures may also have adversely J o u r n a l P r e -p r o o f Journal Pre-proof impacted mental health, which would favor interpersonal violence and self-harm behavior [15] .

The number of emergency medical visits due to abdominal pain, chest pain, and the common cold has also meaningfully reduced after the onset of the pandemic.

Patients with mild symptoms probably did not seek medical care, which would have happened before home confinement measures. On March 23 rd , people were vaccinated against the most common influenza strains (subtype A/H1N1 and H3N2; and subtype B/Victoria) throughout São Paulo city [16] . Flu vaccination can affect the number of fever patients visiting the emergency room, and avoid overburdening health services [16] . Additionally, mask wearing, hand hygiene, and social distancing during the COVID-19 pandemic may have helped to reduce transmission of the common cold [18] .

Some medical conditions did not change after home confinement orders.

These conditions include non-SARS-CoV-2-related acute myocardial infarction and stroke. It is essential for health-care providers to allocate resources for these conditions. Cardiovascular intensive care resources are already burdened by COVID-19-related cardiovascular complications [19] . Additionally, ureterolithiasis, acute cholelithiasis, and acute appendicitis are conditions that have not been reduced after pandemic onset.

Several of these conditions demand surgical intervention, and hospitals have to cope with and address emergency surgeries. Care should be taken to avoid transmission for patients and medical staff during these surgeries [20, 21] .

Giamelllo et al. [22] , in an Italian two-center study that comprises over 45,000 emergency department examinations annually, showed a significant drop in the emergency visits for anxiety, back and joint pain, abdominal pain, general malaise, dizziness in 2020 compared to 2019. Unlike our findings, they observed a reduction in acute coronary syndrome cases. De Filippo et al., [23] , in a study comprising 15 J o u r n a l P r e -p r o o f Journal Pre-proof hospitals in Italy focused on coronary admissions, also showed a significant reduction on acute coronary syndrome on the pandemic period. However, as noted by Vecchio et al. [24] , the number of intensive care admissions for non-primarily cardiac conditions has raised. Probably the reduction on non-SARS-CoV-2 coronary syndrome is due to the fact that several cases of acute myocardial infarction have been diagnosed as COVID-19 related complications [19] . Thus, policymakers should keep special attention on coronary syndrome in the pandemic period, both for SARS-CoV-2 and non-SARS-CoV-2 related conditions. This study has some limitations. The retrospective nature and large sample size of this multicenter work resulted in high heterogeneity among patients, diseases, hospitals, and emergency management protocols. Although the external validity of the present findings is undeterminable, São Paulo showcases all the significant challenges inherent in several worldwide metropolises concerning society's complexity and density, health system network, traffic, and violence, among others. Future populationbased studies will be necessary to determine the validity of the findings of the present study in other major metropolises with longer follow-up. Also, future studies also should focus on the specific mortality, according to each disease category.

The COVID-19 pandemic has changed the non-SARS-CoV-2 emergency profile. The overall number of emergency medical visits has reduced, and the mortality of non-SARS-CoV-2 emergencies has not increased.

The study was not funded. 

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