Impact of COVID-19 pandemic on visits of an urban emergency department

ObjectiveThe aim of this study was to reveal how the pandemic process affected the number of ED visits and the reasons for application.MethodsThe daily number of ED visits during the pandemic were analyzed in 3 different periods; prepandemic period (February 1st to March 11th, declaration of the first COVID-19 case in Turkey), early pandemic period (March 12th to May 31th, period of strict measures), and late pandemic period (June 1st to July 31st, period of new norms). The pandemic periods were compared with the same timeframes in 2019 (comparison periods). Demographic variables and complaints of the patients on admission were investigated.ResultsThe total number of ED visits in the study period in 2020 was 78,907, which was only the half of the applications in the same period in 2019 (n: 149,387). Data showed a sharp decrease at the number of daily visits to green and yellow zones after the announcement of the first case however red zone applications were more than twice that of the previous year. During pandemic nonspecific complaints was decreased and there was an increase at the percentages of respiratory, cardiac, and neurological complaints.ConclusionNumber of ED visits during the pandemic were decreased by half when compared to the previous year. It was an advantage of the pandemic to decrease ED visits due to “nonemergent” complaints, and thus, unnecessary patient burden. However, on the other hand, patients avoided seeking medical attention, even for life-threatening conditions which led to increased mortality and morbidity.     

Surge activation by the emergency department for COVID-19

In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.     

COVID-19 respiratory support in the emergency department setting

IntroductionSevere acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), may result in severe complications, multiorgan dysfunction, acute respiratory failure, and death. SARS-CoV-2 is highly contagious and places healthcare workers at significant risk, especially during aerosol-generating procedures, including airway management.ObjectiveThis narrative review outlines the underlying respiratory pathophysiology of patients with COVID-19 and discusses approaches to airway management in the emergency department (ED) based on current literature.DiscussionPatients presenting with SARS-CoV-2 infection are at high risk for acute respiratory failure requiring airway management. Among hospitalized patients, 10–20% require intensive care unit admission, and 3–10% require intubation and mechanical ventilation. While providing respiratory support for these patients, proper infection control measures, including adherence to personal protective equipment policies, are necessary to prevent nosocomial transmission to healthcare workers. A structured approach to respiratory failure in these patients includes the use of exogenous oxygen via nasal cannula or non-rebreather, as well as titrated high-flow nasal cannula and non-invasive ventilation. This review offers several guiding principles and resources designed to be adapted in conjunction with local workplace policies for patients requiring respiratory support.ConclusionsWhile the fundamental principles of acute respiratory failure management are similar between COVID-19 and non-COVID-19 patients, there are some notable differences, including a focus on provider safety. This review provides an approach to airway management and respiratory support in the patient with COVID-19.     

Characterizing pediatric emergency department visits during the COVID-19 pandemic

ObjectiveWe determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs.MethodsUsing retrospective data from January–June 2020, compared to a similar 2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis.ResultsWe included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis.ConclusionPediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.     

COVID-19 and emergency department volume: The patients return but have different characteristics

BackgroundThe COVID-19 pandemic has altered behaviors in the general population, as well as processes in the healthcare industry. Patients may be afraid to pursue care in the emergency department (ED) due to perceived risk of infection. The objective of this study was to determine the impact of COVID-19 on ED metrics.MethodsAt one metropolitan trauma center ED, we conducted a review of all visits from February to May in 2020 and compared findings with the same months from 2019.ResultsA total of 34,213 ED visits occurred during the study periods (18,471 in 2019 and 15,742 in 2020), with a decline in patient visits occurring after state emergency declarations. In 2020, patients were less likely to be female and more likely to arrive by ambulance. Diagnoses in the musculoskeletal, neurologic, and genitourinary categories occurred in lower proportions in 2020; toxicology, psychiatry, and infectious diseases occurred in higher proportions. In contrast to other insurance categories, Medicare patients comprised a larger share of ED visits in 2020 compared to 2019.DiscussionDespite relatively low local prevalence of COVID-19, we report decreases in ED volume for some medical diagnosis categories. A volume rebound occurred in May 2020, but did not reach 2019 levels. Public health officials should encourage local populations to seek emergency care when concerned, and could consider programs to provide transportation. Patients should continue to protect themselves with social distancing and masks.     

The emergency department care for hemodialysis patient during the COVID-19 pandemic

The COVID-19 pandemic poses significant challenges to patients with end-stage kidney disease who receive treatment in outpatient dialysis centers. These patients represent a fragile population that is at higher risk for both infection and transmission. At the start of the pandemic, many suspected COVID-19 dialysis patients were diverted to the emergency department (ED) for testing/treatment, placing a tremendous burden on the ED and inpatient dialysis units. Several recommendations and guidelines have been established to optimize patient care while also decreasing the burden on the ED and inpatient dialysis units and maximizing the ability to perform outpatient hemodialysis. As the pandemic continues, dialysis facilities will have an increasing burden to provide safe and accessible dialysis, while also being able to direct patients to the ED for either emergent dialysis or COVID-19 treatment/testing. We reviewed opinions, recommendations and guidelines developed by professional organizations and dialysis facilities for the management of “patients under investigation” (PUIs) and COVID-19 positive patients that depend on whether the suspicion occurs while the patient is at home vs. at the dialysis center.     

A model for rapid emergency department expansion for the COVID-19 pandemic

COVID-19 has caused global dramatic change in medical practices including the introduction of temporary screening and assessment areas outside the footprint of the main hospital structures. Following the initial surge of patients with novel coronavirus (2019-nCoV) in the United States, our medical center rapidly designed and constructed an alternative assessment and treatment site in a converted parking garage deck for emergency department patients with suspected or confirmed 2019-nCoV. During the first month after opening, 651 patients were treated in this alternative assessment area including 54 patients who tested positive for 2019-nCoV. This accounted for 55% of the 98 patients with confirmed novel coronavirus (2019-nCoV) who were treated in our ED. This report provides a blueprint for the necessary steps, materials, labor needs and barriers, both anticipated and unanticipated, to rapidly construct an alternative ED treatment site during a pandemic.     

Flattening the other curve: Reducing emergency department STEMI delays during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has been associated with ST-Elevation Myocardial Infarction (STEMI) reperfusion delays despite reduced emergency department (ED) volumes. However, little is known about ED contributions to these delays. We sought to measure STEMI delays and ED quality benchmarks over the course of the first two waves of the pandemic.StudyThis study was a multi-centre, retrospective chart review from two urban, academic medical centres. We obtained ED volumes, COVID-19 tests and COVID-19 cases from the hospital databases and ED Code STEMIs with culprit lesions from the cath lab. We measured door-to-ECG (DTE) time and ECG-to-Activation (ETA) time during the phases of the pandemic in our jurisdiction: pre-first wave (Jan-Mar 2020), first wave (Apr-June 2020), post-first wave (July-Nov 2020), and second wave (Dec 2020 to Feb 2021). We calculated median DTE and ETA times and compared them to the 2019 baseline using Wilcox rank-sum test. We calculated the percentages of DTE ≤10 min and of ETA ≤10 min and compared them to baseline using chi-square test. We also utilized Statistical Process Control (SPC) Xbar-R charts to assess for special cause variation.ResultsCOVID-19 cases began during the pre-wave phase, but there was no change in ED volumes or STEMI quality metrics. During the first wave ED volumes fell by 40%, DTE tripled (10.0 to 29.5 min, p = 0.016), ETA doubled (8.5 to 17.0 min, p = 0.04), and percentages for both DTE ≤10 min and ETA ≤10 min fell by three-quarters (each from more than 50%, to both 12.5%, both p < 0.05). After the first wave all STEMI quality benchmarks returned to baseline and did not significantly change during the second wave. A brief period of special cause variation was noted for DTE during the first wave.ConclusionsBoth DTE and ETA metrics worsened during the first wave of the pandemic, revealing how it negatively impacted the triage and diagnosis of STEMI patients. But these normalized after the first wave and were unaffected by the second wave, indicating that nurses and physicians adapted to the pandemic to maintain STEMI quality of care. DTE and ETA metrics can help EDs identify delays to reperfusion during the pandemic and beyond.     

Pediatric emergency department utilization during the COVID-19 pandemic in New York City

ObjectivesThis study describes the utilization of a pediatric emergency department (ED) during the early months of the COVID-19 pandemic in the initial U.S. epicenter, including the impact on visit acuity and incidences of common diagnoses.Study DesignWe performed an observational retrospective review of patients younger than 18 years old seen in a New York City pediatric ED from March 7th to May 6th 2020, and during the same time period in 2018 and 2019. Demographics, visit details, diagnoses, and dispositions were compared. Validated algorithms were utilized to create practical diagnosis groupings and to determine the probability of a visit requiring emergent evaluation.ResultsED visits during the pandemic decreased by 56% to an average daily census of 67 patients, from an anticipated 152. Admission rates rose from 13.3% to 17.4% (p<0.001), and the proportion of triage Emergency Severity Index level 1 and 2 patients increased by 23.7% (p<0.001). Non-emergent visits dropped from 32.3% to 27.5% (p<0.001). Several common, often low-acuity diagnoses saw disproportionate reductions in visits including headache, chest pain, and minor injuries. Concerningly, visits for suicidal ideation, suicide attempt, or self-harm increased by 100% (p<0.001) and visits for evaluating abuse or neglect decreased by 89% (p=0.01).ConclusionsPediatric ED utilization substantially deceased during the early months of the COVID-19 pandemic in New York City, but left relatively higher patient acuity. Healthcare systems in early epicenters must also prepare for the disproportionate impact a pandemic has on the most vulnerable pediatric patients, particularly those at risk for self-harm or abuse.     

Predicting 30 – Day outcomes in emergency department patients discharged with COVID-19

IntroductionDetermining disposition for COVID-19 patients can be difficult for emergency medicine clinicians. Previous studies have demonstrated risk factors which predict severe infection and mortality however little is known about which risk factors are associated with failure of outpatient management and subsequent admission for COVID-19 patients.MethodsWe conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test collected during an ED visit between March 1, 2020 and October 11, 2020. Patients were divided into two groups based on presence or absence of a subsequent 30-day hospitalization. Clinical and demographic information were collected including chief complaint, triage vital signs and comorbid medical conditions.Results1038 patients were seen and discharged from a network ED with a positive SARS-CoV-2 PCR test. 94 patients (9.1%) were admitted to a hospital within 30 days of the index ED visit while 944 (90.9%) were not admitted to a network hospital within 30 days. Patients that were admitted were more likely to be older (aOR = 1.04 (95% CI 1.03–1.06)), hypoxic (aOR = 2.16 (95% CI 1.14–4.10)) and tachycardic (aOR = 2.13 (95% CI 1.34–3.38)) on initial ED presentation. Preexisting hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease and malignancy were all highly significant risk factors for 30-day hospital admission following initial ED discharge (p < 0.0001).ConclusionEmergency Department providers should consider age, chief complaint, vital signs and comorbid medical conditions when determining disposition for patients diagnosed with COVID-19.     

Upgrades to intensive care: The effects of COVID-19 on decision-making in the emergency department

IntroductionThe initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units.MethodsThe number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses. Charts with non-concordant diagnoses were examined in detail as to the ED medical decision-making, clinical circumstances surrounding the upgrade, and presence of a diagnosis of COVID-19. For each case, a cognitive bias was assigned.ResultsThe percentage of upgraded cases with non-concordant diagnoses increased from a baseline range of 14–20% to 41.3%. The majority of upgrades were due to premature closure (72.2%), anchoring (61.1%), and confirmation bias (55.6%).ConclusionConsistent with the behavioral literature, this suggests that stressful ambient conditions affect cognitive reasoning processes.     

COVID-19:Masks do not influence neurocognitive performance during a shift at the emergency department

<正>The COVID-19 pandemic has led to the widespread mandatory use of personal protective equipment (PPE),including filtering face pieces (FFP). Emergency medical care providers now commonly use this equipment.     

Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS

IntroductionSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases.ObjectiveThis narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.DiscussionIn severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4–8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H₂O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause.ConclusionsThis review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.     

Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department

BackgroundAwake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation.MethodsWe conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation.ResultsWe included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82).ConclusionsAmong COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.