key: cord-1026547-7iioutpk
authors: Leung, William C.Y.; Lau, Eric H.Y.; Kwan, Patrick; Chang, Richard Shek-kwan
title: Impact of COVID-19 on seizures-related emergency attendances and hospital admissions - A territory-wide observational study
date: 2020-09-21
journal: Epilepsy Behav
DOI: 10.1016/j.yebeh.2020.107497
sha: 260d48d4ca25f80955cf8025f9964fd27bc9e2ef
doc_id: 1026547
cord_uid: 7iioutpk

This is a territory-wide study to investigate the impact of COVID-19 pandemic on Accident and Emergency Department (A&E) attendances and acute ward admissions for seizures. Adult patients who presented to the A&E with seizures from January 23, 2020 to March 24, 2020 (study period) were included and compared with parallel intervals from 2015 to 2019 (control periods). Pre-existing time trend in control periods and potential changes during COVID-19 were analyzed by Poisson, negative and logistic regression models. A&E attendances and ward admissions for seizures decreased significantly during the COVID-19 pandemic. A total of 319 and 230 recorded ward admissions and A&E attendances for seizures were identified during the study period in 2020, compared to 494 and 343 per annum respectively in the control periods. The ratio of acute ward admission per A&E attendance for seizures did not change significantly. Intensive care utility and mortality rates remained stable. For some patients, delaying medical attention due to fear of nosocomial COVID-19 cross-infection may lead to severe or even life-threatening consequences. This change in medical help-seeking behavior calls for new medical care models to meet the service gap. Education to epilepsy patients and their caregivers is of utmost importance during this pandemic.

Seizure is a common reason for utilization of emergency hospital services. It is among the top neurological conditions for hospital admission [1] . The outbreak of Coronavirus Disease 2019 (COVID-19) has quickly evolved from a regional epidemic to a global pandemic. This has imposed a huge challenge on healthcare systems around the world. The first case of COVID-19 in Hong Kong was confirmed on January 23, 2020 [2] . This led to a series of emergency infection protocols in public hospitals in our locality [3] . There is increasing concern that these measures might have impacted patients' health seeking behavior for non-COVID-19 conditions, particularly chronic diseases. We hypothesized that COVID-19 had affected the utility of emergency medical service of patients with seizures. By analyzing data from a territory-wide computerized database, we compared the Accident and Emergency Department (A&E) attendance and ward admissions of patients for seizures before and during the outbreak of COVID-19. The diagnosis codes and other admission data are recorded in the CDARS.

The study period was between January 23, 2020 and March 24, 2020. Control periods were the parallel intervals, from January 23 to March 24, from year 2015 to 2019. The lunar New Year holiday in Hong Kong, usually in late January / early February, may transiently affect the local admission rate. However, the periods of interest completely covered the holiday in all the 6 years included, thereby controlling for any possible impact of this factor in the analysis. The population of Hong Kong was stable at around 7.4 million during the years of study.

For both A&E attendance and acute ward admission cases, eligible patients were adults aged 18 years or above with a principal diagnostic label of "Epilepsy" (ICD9 345.0 -345.9) or "Convulsions" (ICD9 780.3). Non-emergency admissions were excluded. The ratio of acute ward admissions was obtained by dividing the number of acute ward admissions for seizures by the number of A&E attendance for seizures.

Several outcome measures were compared and analyzed. The lengths-of-stay (LOSs) in the acute ward, High Dependence Unit/Intensive Care Unit (HDU/ICU) and rehabilitation wards were recorded as the total days spent in each unit during each admission. Mortality rate was the proportion of patients who died during admission for the aforementioned ICD codes in the study period. Early A&E re-attendance and acute ward re-admission rates were defined as such within 28 days. The data from the study period were then compared with those in the control periods. Poisson regression and negative binominal regression were used to analyze the trend of hospitalization parameters of seizure patients in the period of interest. Logistic regression was performed to study the mortality risk, acute ward re-admission and A&E re-attendance rates. We accounted for pre-existing time trend and examined potential change during the study period after COVID-19 outbreak in 2020. Statistical analysis was performed with IBM SPSS 22.0 for Windows and R version 3.6.3 (R Development Core Team, Vienna, Austria). Statistical significance is considered at P < 0.05.

This study was approved by the institutional review board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster. Informed consent was waived by the board as the clinical data were anonymized.

A total of 319 eligible acute ward admissions were identified in the COVID-19 study period, while 2469 admissions were recruited in total from the control periods from 2015 -2019. The background yearly trend was relatively stable ( Figure) (Table) . There was a significant drop in LOSs in acute wards and rehabilitation wards in the time trend (Table) . The LOSs in HDU/ICU for seizure remained stable. Mortality risk associated with seizures also did not have significant change in the study period. Early A&E re-attendances (for seizure) and acute ward re-admissions (for both seizure and all causes) all demonstrated a significant decline (Table and Figure) .

This is a territory-wide observational study to investigate the impact of COVID-19 pandemic on the medical help-seeking behavior by seizure patients. It specifically examined the hospital service utility parameters including hospital attendances and admissions, length of stay and early re-admission rates.

In the medical system of Hong Kong, a patient with an emergent condition usually first presents to the A&E. An emergency specialist will triage the patient to acute ward, A&E observation room or direct discharge [4] . Our results showed significant year. Although public hospital management has reviewed the provision of non-urgent services such as elective admissions and procedures, the policy for emergency services has theoretically been maintained.

A shortened mean LOSs in acute and rehabilitation wards for seizure patients was noted after COVID-19 outbreak. Both clinicians and patients might prefer to minimize the hospital stay once the patient's condition has been stabilized. This however did not lead to increased rates of early re-hospitalization or re-attendance.

The mortality rate and the length of HDU/ICU stay was largely comparable to the baseline. This may reflect that the occurrence of severe conditions associated with seizure was not altered by the pandemic.

Change in medical help-seeking behavior among patients may be multifactorial. Fear of nosocomial cross-infection of COVID-19 and avoidance to overload the hospital system may be some of the reasons [5] . Although such concerns are understandable, delay in seeking medical attention may be at the expense of optimal and timely investigation and management. Seizure or epilepsy per se has been not shown to increase the risk of COVID-19 infection. Theoretical risk may apply to those who J o u r n a l P r e -p r o o f Journal Pre-proof have epileptic disorders associated with syndromal, co-morbid, and therapy-related deficiencies in the immune system. The International League Against Epilepsy (ILAE) advises that patients with seizure may spare a visit to A&E only if there is absence of life-threatening features or complications [6] . However, patients who were managed at home may experience a lower quality of life, due to disruption of normal social services and provision of public facilities.

The enormous societal impact of the COVID-19 pandemic has provided a strong impetus to reflect and evaluate our healthcare systems, and to put forward innovative and comprehensive medical care models to address any unmet demands. For example, telemedicine has recently attracted great attention, with evidence to support its use in epilepsy groups [7, 8] . While this technology may be common in some parts of the world, it is still not popular in population-dense localities such as Hong Kong with convenient accessibility to healthcare. Cultural and habitual differences may also be hurdles among clinicians and patients. However This study has limitations. Patients with seizure presentation belong to a heterogeneous group. They include first-ever seizures, either unprovoked or with apparent precipitating causes, and breakthrough seizure of known epilepsy disorders.

We are unable to perform subgroup analysis in different causes of seizure. We are also unable to capture the seizure severity of each episode from the electronic database. It is possible that only patients with more severe seizures attended the A&E during the pandemic. Presentations to primary care for possibly milder seizures were not included in the analysis. We assumed that the incidence of seizure in the 

None of the authors has any conflict of interest to disclose.

We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

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

Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study BMJ Open

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