key: cord-0979696-ca6gy8k4
authors: Walker, Laura E.; Heaton, Heather A.; Monroe, Ryan J.; Reichard, R. Ross; Kendall, Monica; Mullan, Aidan F.; Goyal, Deepi G.
title: Impact of the SARS-CoV-2 Pandemic on Emergency Department Presentations in an Integrated Health System
date: 2020-09-19
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.09.019
sha: 69090343c2071c92e9238aa0fc099e7de97f2a40
doc_id: 979696
cord_uid: ca6gy8k4

Objective To quantify the impact of the SARS-CoV-2 pandemic on emergency department volumes and patient presentations, and to evaluate changes in community mortality for the purpose of characterizing new patterns of emergency care utilization. Patients and Methods This is an observational cross-sectional study using electronic health records for emergency department visits in an integrated, multi-hospital system with academic and community practices across four states for visits between March 17 to April 21, 2019, and February 9 to April 21, 2020. We compared numbers and proportions of common and critical chief complaints and diagnoses, triage assessments, throughput, disposition, and selected hospital lengths of stay and out-of-hospital deaths. Results In the period of interest, emergency department visits decreased by nearly 50%. Total number of patients diagnosed with myocardial infarctions, stroke, appendicitis and cholecystitis decreased. The percentage of visits for mental health complaints increased. There was an increase in deaths, driven by out-of-hospital mortality. Conclusion Fewer patients presenting with acute and time-sensitive diagnoses suggests that patients are deferring care, this may be further supported by an increase in out of hospital mortality. Understanding which patients are deferring care and why will allow us to develop outreach strategies and ensure that those in need of rapid assessment and treatment will do so, preventing downstream morbidity and mortality.

The onset of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- pandemic in the United States has brought significant changes to the operations of our healthcare system and country. Efforts to mitigate the spread of the novel coronavirus resulted in healthcare systems cancelling all but the most urgent visits and developing plans to manage surges of critically ill patients. As noted in media reports from across the country 1, 2, 3, 4, 5 

ST-elevation myocardial infarctions (STEMI) 6, 7, 8 and ischemic strokes 9 , suggesting that patients may be deferring care for serious conditions whose prevalence would be expected to be stable.

year-over-year comparisons, exploring concerns that patients may be deferring care due to fear of exposure to the novel coronavirus 10 . These fears further extrapolate to concerns that delays in emergency care may lead to more individuals dying at home 11 . No study to date has objectively assessed the impact of the COVID-19 pandemic on presentations to EDs.

In this study we aimed to characterize the impact of the COVID-19 pandemic on volume, chief complaint, and characteristics of patients presenting to 21 EDs across an integrated health system in four states. We also assess the impact on the rates of out-of-hospital deaths in an 8county region in Minnesota.

This study was approved by our institutional IRB and reporting adheres to the STROBE guideline for reporting epidemiological studies 12 . A protocol was written prior to beginning the study.

Mayo Clinic is a hospital system with three academic tertiary care centers ( 

All patients who presented to the any Mayo Clinic ED during the study periods between February 9 and April 21 in 2019 and 2020 were included, with the following predefined exceptions: urgent care visits, nurse only visits. 91,353 patient visits were included.

We defined March 17 -April 21, 2020 as the time after the broad institution of distancing measures in response to the COVID-19 pandemic and term this the "COVID" period.

To account for seasonal variation seen in emergency medicine, we compared this to both the four weeks prior to the COVID period (February 9 to March 16, 2020), and to the same time period in 2019 (March 17 to April 21). We termed these baseline comparators the "peri-COVID" and J o u r n a l P r e -p r o o f "pre-COVID" periods, respectively, and the aggregate is termed the "baseline" period. Figure 1 includes the complete listing of all variables analyzed.

Discrete fields in the EHR were queried to obtain the data for individual visits.

Community mortality data were acquired from ME records.

Only information available in the EHR and from the ME was included in this analysis.

Academic and community centers were studied independently and in combination to account for variable populations. These data are representative of the range of care and communities served by our institution, and may not be generalizable for all health care systems. The ME data is J o u r n a l P r e -p r o o f representative of only a subset of our communities and may not be generalizable to the entire health system that was evaluated for ED visits.

Our analysis for the peri-COVID and COVID period in early 2020 included 56 Trauma presentations in our system are classified as "green" (minor), "yellow", and "red" (severe). Compared to both baselines, the percentages of traumas were similar, however, the absolute number of red (n= 35 during COVID; n=72 peri-COVID; n=67 pre-COVID) and yellow (n=58 during COVID; n=97 peri-COVID; n=93 pre-COVID) declined overall, driven by a drop at academic centers by nearly 60% for red traumas and 50% for yellow.

In addition to the diagnoses, we evaluated hospital LOS for patients with appendicitis and cholecystitis as a surrogate for a complicated hospital course, with the assumption that a longer LOS may be indicative of complications, potentially due to delayed presentation. There was no increased hospital LOS for either appendicitis or cholecystitis patients.

Mortality was considered a surrogate for delayed/deferred emergency care. Southern Table 2 )

Key results

suggest that patients who did present were sicker than those in the baseline periods.

We found declines in the absolute number of patients with STEMI, non-STEMI, stroke, appendicitis, cholecystitis, which would not be expected to result from social distancing measures. With fewer of these time-sensitive diagnoses being made in EDs, there is concern that delayed or deferred care may result in downstream morbidity (heart failure, hemi-paresis e.g.) or mortality. We did not find evidence of prolonged hospital stay for appendicitis/cholecystitis patients, suggesting that although we are seeing smaller numbers there is no morbidity increase, using this as a surrogate.

There was a decline in the number of patients with a mental health diagnosis class, however the proportion of patients who presented increased. This indicates that patients with mental health concerns continued to visit the emergency department when other potential patients chose to defer care.

During the COVID era, there was an increase in ME-reported natural (non-COVIDrelated) deaths compared to baseline periods, which is extremely concerning. Recognizing the limitations of these data and that this represents correlation and not causation, this supports the concern that patients are deferring emergency care resulting in mortality. 

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

Patients with heart attacks, strokes and even appendicitis vanish from hospitals. The Washington Post. Health

Health officials: Emergency rooms are open. Rochester Post Bulletin. Covid-19 Coverage

Fewer people are going to Triangle emergency rooms, and that could be a bad thing. The News and Observer. Local

As heart attack rates plummet, doctors worry patients are avoiding the ER

Where have all the heart attacks gone? The New York Times. Doctors

Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy