Emergency department operations in a large health system during COVID-19

Impact of the Early COVID-19 Pandemic on Emergency Department Visits of Adult Cancer Patients With Fever or Respiratory Symptoms: A Korean Nationwide Population-Based Study, 2016-2020

BACKGROUND

We performed a nationwide analysis to evaluate the impact of the early coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) visits by adult cancer patients having COVID-like symptoms.

METHODS

We analyzed the National Emergency Department Information System (NEDIS) data on ED visits by adult cancer patients who presented with chief complaints of fever or respiratory symptoms (FRS) indicative of COVID-19, from 2016 to 2020. An interrupted time series analysis with a quasi-Poisson regression model was performed, adjusting for seasonality and time, to evaluate whether underlying trends for monthly ED visits and the in-hospital mortality rate (%) per month changed with the pandemic among these patients. We also estimated the adjusted odds ratio (aOR) of in-hospital deaths among cancer patients using multivariable logistic regression analysis.

RESULTS

ED visits by cancer patients with FRS decreased during the COVID-19 pandemic (relative risk [RR] with 95% confidence interval [CI]: slope change, 0.99 [0.98-1.00] and step change, 0.84 [0.76-0.92]). However, the in-hospital mortality rate (%) for these patients was increased (slope change, 1.14 [1.04-1.25] and step change, 0.99 [0.98-1.01]). Factors such as urgent triage status, ambulance use, and treatment in hospitals with fewer than 300 staffed beds significantly contributed to increased aOR of in-hospital deaths during the COVID-19 pandemic compared to the pre-pandemic period.

CONCLUSION

Further studies are needed to highlight the importance of ED service preparation in planning and managing resources for cancer patients during future pandemics.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BACKGROUND

The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics.

OBJECTIVE

This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area.

METHODS

The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions.

RESULTS

The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations.

CONCLUSIONS

Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Emergency care utilization and patients' outcome before and after COVID-19 national lockdown in Iran: a cross-sectional study

INTRODUCTION

COVID-19 rapidly spread throughout the world. Stay-at-home and social distance strategies accompanied by fear of contamination with COVID-19 caused significant disruptions in daily life. The study focused on the impact of the COVID-19 pandemic on emergency visit and patients' outcome in the emergency department (ED).

METHOD

Administrative and clinical data of 25-hospital EDs in Kermanshah province of Iran from February 20, 2020, to February 18, 2021, were retrospectively analyzed with the comparable periods in the previous year. The incidence rate ratio (IRR) was used to compare the differences between the pandemic and the pre-pandemic period.

RESULT

The number of ED visits decreased nearly 50% after the declaration of a national lockdown. Moreover, the proportion of patients triaged in ESI 1 and 2 levels increased by 40 and 52%, respectively. The ratio of patients admitted to intensive care units and discharged against medical advice also increased significantly.

CONCLUSION

Despite the number of ED visits sharply declining, the ratio of patients who came to EDs with higher acuity significantly increased. So, health authorities must sensitize the public about life-threatening signs and symptoms in such conditions.

Boarding in US Academic Emergency Departments During the COVID-19 Pandemic

STUDY OBJECTIVE

The first 2 years of the COVID-19 pandemic brought substantial and dynamic changes to emergency department volumes and throughput. The objective of this study was to describe changes in ED boarding among US academic EDs across the duration of the COVID-19 pandemic.

METHODS

We conducted a retrospective analysis of monthly data collected from a convenience sample of academic departments of emergency medicine. The study period was from January 2019 to December 2021. The primary outcome was total boarding hours, and secondary outcomes included patient volume stratified by ED disposition. We used multivariable linear panel regression models with fixed effects for individual EDs to estimate adjusted means for 3-month quarters.

RESULTS

Of the 73 academic departments of emergency medicine contacted, 34 (46.6%) participated, comprising 43 individual EDs in 25 states. The adjusted mean total boarding hours per month significantly decreased during the second quarter of 2020 (4,449 hours; 95% confidence interval [CI] 3,189 to 5,710) compared to the first quarter of 2019 (8,521 hours; 95% CI 7,845 to 9,197). Beginning in the second quarter of 2021, total boarding hours significantly increased beyond pre-pandemic levels, peaking during the fourth quarter of 2021 (12,127 hours; 95% CI 10,925 to 13,328).

CONCLUSIONS

A sustained and considerable increase in boarding observed in selected US academic EDs during later phases of the COVID-19 pandemic may reflect ongoing stresses to the health care system, with potential consequences for patient outcomes as well as clinician well-being.

Impact of sequential capacity building on emergency department organisational flow during COVID-19 pandemic: a quasi-experimental study in a low-resource, tertiary care centre

INTRODUCTION

A quasi-experimental study was conducted to estimate the impact of sequential emergency department (ED) capacity building interventions on key performance indicators such as patients' length of stay (LOS) and wait time (WT) during the COVID-19 pandemic. This was achieved through augmenting personnel education and head count, space restructuring and workflow reorganisation.

SETTING AND PARTICIPANTS

This study included 268 352 patients presenting from January 2019 to December 2020 at Indus Hospital and Health network Karachi, a philanthropic tertiary healthcare facility in a city of 20 million residents. A follow-up study was undertaken from January to December 2021 with 123 938 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

These included mean and median ED-LOS and WT for participants presenting in different cohorts. The results of the pre-COVID-19 year 2019 (phase 0) were compared with that of the COVID-19 year, 2020 (phases 1-3 corresponding to peaks, and phase 4 corresponding to reduction in caseloads). The follow-up was conducted in 2021 to see the sustainability of the sequential capacity building.

RESULTS

Phases 1, 2 and 3 had a lower mean adjusted LOS (4.42, 3.92 and 4.40 hours) compared with phase 0 (4.78 hours, p<0.05) with the lowest numbers seen in phase 2. The same held true for WT with 45.1, 23.8 and 30.4 min in phases 1-3 compared with 49.9 in phase 0. However, phase 4 had a higher LOS but a lower WT when compared with phase 0 with a p<0.05.

CONCLUSION

Sequential capacity building and improving the operational flow through stage appropriate interventions can be used to off-load ED patients and improve process flow metrics. This shows that models created during COVID-19 can be used to develop sustainable solutions and investment is needed in ideas such as ED-based telehealth to improve patient satisfaction and outcomes.

The impact of COVID-19 on emergency department boarding and in-hospital mortality

INTRODUCTION

The COVID-19 pandemic has been challenging for healthcare systems in the United States and globally. Understanding how the COVID-19 pandemic has impacted emergency departments (EDs) and patient outcomes in a large integrated healthcare system may help prepare for future pandemics. Our primary objective was to evaluate if there were changes to ED boarding and in-hospital mortality before and during the COVID-19 pandemic.

METHODS

This was a retrospective cohort study of all patients ages 18 and over who presented to one of 17 EDs (11 hospital-based; 6 freestanding) within our healthcare system. The study timeframe was March 1, 2019- February 29, 2020 (pre-pandemic) vs. March 1, 2020-August 31, 2021 (during the pandemic). Categorical variables are described using frequencies and percentages, and p-values were obtained from Pearson chi-squared or Fisher's exact tests where appropriate. In addition, multiple regression analysis was used to compare ED boarding and in-hospital mortality pre-pandemic vs. during the pandemic.

RESULTS

A total of 1,374,790 patient encounters were included in this study. In-hospital mortality increased by 16% during the COVID-19 Pandemic AOR 1.16(1.09-1.23, p < 0.0001). Boarding increased by 22% during the COVID-19 pandemic AOR 1.22(1.20-1.23), p < 0.0001). More patients were admitted during the COVID-19 pandemic than prior to the pandemic (26.02% v 24.97%, p < 0.0001). Initial acuity level for patients presenting to the ED increased for both high acuity (13.95% v 13.18%, p < 0.0001) and moderate acuity (60.98% v 59.95%, p < 0.0001) during the COVID-19 pandemic.

CONCLUSION

The COVID-19 pandemic led to increased ED boarding and in-hospital mortality.

Outcomes in patients with acute stroke treated at a comprehensive stroke center using telemedicine versus in-person assessments

INTRODUCTION

Telemedicine has been shown to be a safe and effective modality to assess and treat patients with acute stroke who present to a community hospital. There are no previous reports on using telemedicine to treat patients with acute stroke who present to a comprehensive stroke center. We report here the outcomes of patients with acute stroke treated in 2021 at our comprehensive stroke center using telemedicine versus an in-person assessment.

METHODS

Patients with acute ischemic stroke who were treated after either a telemedicine or in-person assessment at our hospital in 2021 were identified by a retrospective chart review. The primary outcomes collected were door-to-needle (DTN) time for alteplase (tPA) administration, door-to-puncture (DTP) time for endovascular thrombectomy, symptomatic intracranial hemorrhage (sICH) rates and 3-month mortality.

RESULTS

There were 302 patients with acute stroke treated at our hospital in 2021. Of these, 18.2% (n = 55/302) were treated using telemedicine. There were no differences in any of the outcomes between patients treated using telemedicine versus an in-person assessment: DTN (35.5 min (n = 42) vs 33 min (n = 182), p < 0.76), DTP (86.5 min (n = 30) vs 85 min (n = 134), p < 0.97), sICH (0% (n = 0/55) vs 1.6% (n = 4/245, p < 0.59) or 3-month mortality (20.6% (n = 7/34) vs 22.1% (n = 40/181), p < 0.29).

DISCUSSION

To the best of our knowledge, this is the first study to report on outcomes for acute stroke patients treated using telemedicine at a comprehensive stroke center. In this study, there were no differences in outcomes between patients treated using telemedicine versus an in-person assessment.

Relationship Between a State-Directed Lockdown on Non-COVID-19-related ICU Admissions and Mortality in a Multicenter Colorado Healthcare System

Colorado issued a month long statewide lockdown on March 26, 2020, during the initial surge of the COVID-19 pandemic. The impact of this mandate on non-COVID-19 ICU admission rates and outcomes is unclear.

DESIGN

We performed a retrospective analysis of all medical ICU admissions in the University of Colorado Health System in four predefined periods: 1) prepandemic (2 mo prior to lockdown period 1); 2) mandated lockdown from March 26 to April 26, 2020 (period 2); 3) between surges (period 3); and 4) nonmandated lockdown surge (between November 1, 2020, and March 31, 2021, period 4).

SETTING

Nonsurgical ICU admissions at the University of Colorado Health Systems, including 10 hospitals throughout Colorado.

SUBJECTS

All ICU admissions in four predefined time periods.

MEASUREMENTS AND MAIN RESULTS

We included 13,787 patients who were admitted during the four study periods. The 28-day mortality rates for non-COVID-19 ICU admissions following index ICU admission were 13.6%, 18.0%, 13.5%, and 16.0% across periods 1-4, respectively. However, the increased odds in non-COVID-19 ICU mortality during the mandated lockdown period relative to prepandemic 1 (odds ratio [OR], 1.39; 95% CI, 1.11-1.72; p = 0.0.04) was attenuated and nonsignificant after adjustment for demographics, comorbidities, diagnosis flags, and severity (OR, 1.15; 95% CI, 0.89-1.48; p = 0.27). Similar results were found in time-to-event analyses. The most common diagnosis in each time period was acute respiratory failure (ARF), and we found it to have increased during lockdown (p < 0.001), whereas sepsis admissions increased during and decreased after lockdown (p = 0.004). Admissions for alcohol withdrawal syndrome (AWS) increased during lockdown and 6 months afterwards (p = 0.005).

CONCLUSIONS

For non-COVID-19-related ICU admissions, mortality rate was similar before, during, and after Colorado's month long lockdown after confounder adjustment, including typical ICU admission flags. Primary admission diagnoses shifted throughout the predefined study periods with more admissions for severe critical diagnoses (i.e., ARF, sepsis, AWS) occurring during the mandated lockdown and nonmandated lockdown periods compared with the prepandemic and between surge period. This would suggest that the perceived increase in mortality during the lockdown for non-COVID-19 ICU admissions may be related to a shift inpatient demographics.

Examining patient flow in a tertiary hospital's emergency department at a low coronavirus prevalence region

BACKGROUND

Taiwan's successful containment of the COVID-19 outbreak prior to 2021 provided a unique environment for the surveillance of unnecessary emergency medical use. The aim of the study is to examine the impact of the coronavirus disease (COVID-19) pandemic on the patient flow in the emergency department (ED) of a tertiary hospital over 1 year in southern Taiwan, a region with low COVID-19 prevalence.

METHODS

Cross-sectional observational study was conducted from January to December 2020. Essential parameters of patient flow in the ED between January and February 2020 and the subsequent 11-month period were compared to data from 2019. Data were analyzed with descriptive statistics, using an independent sample t-test or Mann-Whitney U test, as applicable.

RESULTS

The ED census showed an acute decline (- 30.8%) from January to February 2020, reaching its nadir (- 40.5%) in April 2020. From February to December 2020, there was an average decrease of 20.3% in ED attendance (p < 0.001). The impact was most significant in ambulatory visits, lower-urgency acuity (level III) visits, and pediatric visits, without change in the acuity proportion. The length of stay shortened mainly in the adult division, which typically had an overcrowding problem (median, 5.7-4.4 hours in discharge; 24.8-16.9 hours in hospitalization; p < 0.001). The incidence of 72-hour unscheduled return visits was also reduced (4.1-3.5%, p = 0.002).

CONCLUSIONS

In contrast to devastated regions, the impact on the ED patient flow in regions having low COVID-19 prevalence highlights a remodeling process of emergency medical care that would improve overcrowding.

Impact of the COVID pandemic on emergency department CT utilization: where do we go from here?

Purpose

To analyze the impact of the coronavirus disease (COVID) pandemic on emergency department (ED) computed tomography (CT) utilization.

Methods

A retrospective observational study was conducted assessing seven hospitals’ ED imaging volumes between Jan. 6, 2019, and Feb. 27, 2021. Weekly CT utilization is reported as CTs ordered per 100 ED visits. Utilization was ascertained in aggregate and by body area. Interrupted time series analysis was performed to assess significance of utilization change. Prespecified sensitivity analysis was performed for influenza-like or COVID-like illness (ILI/CLI).

Results

Weekly ED CT utilization increased from 35.9 CTs per 100 visits (95% confidence interval [95% CI] 35.8–36.1) to 41.8 per 100 visits (95% CI 41.7–42.0) in pre- and post-pandemic periods. Weekly ED CT chest utilization increased immediately following the pandemic declaration (+ 0.52 chest CTs per 100 ED visits, 95% CI 0.01–1.03, p < 0.05) and compared to pre-pandemic period (+ 0.02 per 100 ED visits, 95% CI 0.02–0.05, p < 0.02). For both CT abdomen/pelvis and CT head, there was neither an immediate effect (+ 0.34 CT-AP per 100 ED visits, 95% CI − 0.74 to 1.44, p = 0.89; − 0.42 CT-H per 100 ED visits, 95% CI − 1.53 to 0.70, p = 0.46) nor a change in weekly CT utilization (+ 0.03 CT-AP per 100 ED visits, 95% CI − 0.01 to 0.05, p = 0.09; + 0.03 CT-H per 100 ED visits, 95% CI − 0.01 to 0.06, p = 0.10). 

Conclusion

These data may help formulate future strategies for resource utilization and imaging operations as we envision a future with COVID and other federal mandates affecting imaging utilization and appropriateness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10140-022-02071-z.

Impact of COVID-19 pandemic on patients with cardio/cerebrovascular disease who visit the emergency department

Introduction

The coronavirus disease 2019 (COVID-19) pandemic situation is a state that has had a great impact on the medical system and society. To respond to the pandemic situation, various methods, such as a pre-triage system, are being implemented in the emergency medical field. However, there are insufficient studies on the effects of this pandemic situation on patients visiting the emergency department (ED), especially those with cardio/cerebrovascular diseases (CVD)¹ classified as time-dependent emergencies.

Methods

We performed a retrospective analysis of a cohort of patients from April 2020 to December 2020 (April 2020 was when the pre-triage system was established) compared to a parallel comparison patient cohort from 2019. The primary outcome was in-hospital mortality. CVD was defined by the patient's final diagnosis.

Results

During the same period, the number of patients who had visited the ED after COVID-19 had decreased to 79.1% of the number of patients who had visited the ED before COVID-19. The overall patient mortality and the mortality in the patients cardiovascular disease had both increased, while the mortality from cerebrovascular disease did not increase. Meanwhile, the ED length of stay had increased in all patients but did not increase in the patients with cardiovascular disease.

Conclusion

As with prior studies conducted in other regions, in our study, the total number of ED visits were decreased compared to before COVID-19. The overall mortality had increased, particularly in the patients with cardiovascular disease.

Flow impacts of hot/cold zone infection control procedures during the COVID-19 pandemic in the emergency department

Background

The COVID-19 pandemic forced emergency departments (EDs) to change operations to minimize nosocomial infection risk. Many EDs cohort patients using provincial screening tools at triage. Despite cohorting, staff exposures occurred in the ‘cold zone’ due to lack of personal protective equipment (PPE) use with patients deemed low risk, resulting in staff quarantines. The cohorting strategy was perceived to lengthen time to physician initial assessment and ED length of stay times in our ED without protecting staff well enough due to varying PPE use. The objective of this study was to assess the impact of hot/cold zones for patient cohorting during a viral pandemic on ED length of stay.

Methods

We conducted an interrupted time series analysis 3 weeks before and after the removal of hot/cold zone care space cohorting in our ED. In the before period, staff did not routinely wear full PPE to see cold zone patients. After removal, staff wore full PPE to see almost all patients. We collected data on ED length of stay, physician initial assessment times, arrival-to-room times, patient volumes, Canadian Triage Acuity Score (CTAS), admissions, staff hours of coverage, as well as proportions of patients on droplet/contact precautions and COVD-19 positive patients. The primary outcome was median ED length of stay.

Results

After the removal of the hot/cold divisions, there was a decrease in the adjusted median ED length of stay by 24 min (95% CI 14; 33). PPE use increased in the after arm of the study. The interrupted time series analysis suggested a decrease in median ED length of stay after removal, although the change in slope and difference did not reach statistical significance.

Conclusion

Cohorted waiting areas may provide a safety benefit without operational compromise, but cohorting staff and care spaces is likely to compromise efficiency and create delays.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-022-00278-0.

Review article: Impact of pandemics on rural emergency departments: A scoping review

Pandemics can cause much distress to communities and present a major burden to the resources and functioning of hospitals. This scoping review aimed to identify, evaluate and summarise current literature regarding how pandemics impact rural EDs in terms of staff wellbeing, structure, function and resources. A systematic search of six databases using search terms including pandemic, ED and rural and remote was undertaken. Articles were included if they were peer-reviewed, written in English, original research, published between January 2010 and October 2021 and discussed the impact of pandemics on rural EDs. Articles were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Three articles, one from Canada and two from the United States, met the inclusion criteria. The articles included were quantitative in design and fulfilled most of the MMAT critical analysis criteria. Pandemics reported on included H1N1 and COVID-19. These pandemics impacted rural EDs in terms of functioning and resourcing; no description of staff wellbeing or structure was identified. Rural ED functioning was affected in terms of input; with an increase in patient presentations and time to physician assessment during H1N1, but a decrease in patient presentations and transfers during COVID-19. Rural ED resources were impacted in regard to staffing, difficulty in obtaining stocks of personal protective equipment and medication, and community response. Further research to understand and address the short- and long-term impacts pandemics may have on rural EDs is required.

Operational Effect of COVID-19 on Surgical Care at a Tertiary Pediatric Hospital

The detrimental effects of the coronavirus disease 2019 (COVID‐19) pandemic have profoundly disrupted surgical care at health care facilities worldwide. At our tertiary pediatric hospital, we made substantial adjustments to surgical suite utilization and staff member scheduling to account for reductions in surgical volume, increased demand for staff members in other sectors of the hospital, and the highly infectious properties of the virus. Perioperative leaders took advantage of the pandemic’s disruption to clinical activities to design and implement a new procedure‐scheduling process to rectify the inefficiencies that had accumulated as the previous system evolved. The implementation of said directives was largely facilitated by establishing communication with all involved parties for their input and feedback throughout the process. Although COVID‐19 has had varying effects on procedural operations across pediatric health care facilities, we believe our institutional response to the disruptive forces of COVID‐19 is of benefit to pediatric hospitals worldwide.

Patients who leave the Emergency Department without being seen. Has COVID-19 affected this phenomenon?

BACKGROUND AND AIM

Patients who present to an Emergency Department (ED) and leave without being seen by a physician represent a safety concern because they may become severely ill and experience adverse events as a result of lacking or delayed ED treatment. Prior to the COVID-19 outbreak, the increasing number of patients accessing care through the ED in Italy and throughout the world has had implications for health policies.

METHODS

A retrospective cohort study that included all ED visits from 1st January 2013 to 31st December 2018 in the Perugia University Hospital has been carried out.

RESULTS

During the 5 years investigated 26,344 out of 300,372 (8.77%) patients who attended the ED left the triage area before being seen with an average of 439 patients per month. The same phenomenon has been analysed from February to October 2020. During these 9 months there were a total of 1,824 out of 30,990 (5.88%) patients who left the ED without being seen with an average of 202 per month. The latter value is one third lower than the one related to the period investigated prior to the COVID-19 outbreak.

CONCLUSIONS

Such investigation could help to differentiate actual essential demand from non-essential demand within the ED, which could inform quality-improvement policies. Several strategies could be implemented to lower the proportion of patients who leave the department without being seen. Reorganising the activities in the ED with different paths should be implemented with the aim of reducing waiting times and in turn patients' satisfaction.

New-onset haemoptysis and associated lung mass in the setting of dental care avoidance during the COVID-19 pandemic

We present a case of new-onset haemoptysis and associated lung lesion on chest imaging in the setting of the COVID-19 pandemic. This was believed to be due to dental care avoidance after tooth fracture and long-term use of temporary dental filler, with subsequent aspiration and bronchial injury. Our patient underwent bronchoscopy due to persistent haemoptysis with findings of mild traumatic injury. She responded to conservative management with no pharmacologic intervention. With time, there was resolution of symptoms and radiographic improvement of the lung lesion. We include a brief discussion on the influence of the COVID-19 pandemic on healthcare avoidance, complications of tooth fracture and the differential diagnosis of a new solitary lung lesion on chest imaging.

[Analysis of ENT emergency patients during the COVID-19 pandemic in Germany]

BACKGROUND

This retrospective observational study was undertaken to assess the ENT emergency workload during the COVID-19 pandemic caused by the severe acute respiratory coronavirus‑2 (SARS-CoV-2).

MATERIALS AND METHODS

All 3230 patients who were treated as an emergency from 23.01.2020 to 06.08.2020 in the Department of Otolaryngology at the SLK-Kliniken Heilbronn were included in this study. Demographic data, diagnostics, diagnosis, and treatment (in-/outpatient) were retrospectively retrieved. Not only did the physicians on call triage the emergency department (ED) ENT patients, but the patients also self-assessed their urgency of treatment.

RESULTS

The number of patients consulting our ED decreased significantly during the pandemic, by 42.2%. However, the top diagnoses remained almost constant, with epistaxis being the most frequent diagnosis before, during, and after COVID-19. Facial trauma remained the second most frequent consultation reason. The hospitalization rate decreased from 21.9% before COVID-19 to 16.2% during the pandemic. Surgical therapy was necessary in 17.6% of patients before COVID-19 and this increased to 23.5% during COVID-19. The self-referral rate increased from 61 to 66% during the pandemic. More men than women consulted the ED during COVID-19. Regarding the triage assessment by the physician on call and the patient's self-assessment, a significant discrepancy was noted before, during, and after COVID-19.

CONCLUSION

The reasons for reduction in ENT ED visits are multifactorial. The clinical consequences of decreased hospitalizations remain uncertain. However, health authorities need to advocate the safety of the hospital environment to limit potential damage.

Beyond the emergency department: Effects of COVID-19 on emergency medicine resident education

BACKGROUND

In December 2019, a novel coronavirus (COVID-19) caused widespread clinical disease, triggering limited in-person gatherings and social-distancing guidelines to minimize transmission. These regulations led most emergency medicine (EM) residency training programs to rapidly transition to virtual didactics. We sought to evaluate EM resident perceptions of the effects of COVID-19 on their didactic and clinical education.

METHODS

We performed a cross-sectional survey study at seven EM residency programs using a mixed-methods approach designed to understand resident perceptions regarding the impact of COVID-19 on their educational experience. Quantitative data were presented as percentages with comparison of subgroups, while open-ended responses were analyzed using qualitative methodology.

RESULTS

We achieved a 59% response rate (187/313). The majority of respondents (119/182, 65.4%) reported that the COVID-19 pandemic had a negative impact on their residency education with junior residents disproportionately affected. A total of 81 of 182 (44.5%) participants reported that one or more of their clinical rotations were partially or completely canceled due to the pandemic. Additionally, we identified four themes and 34 subthemes highlighting the contextual effects of the pandemic, which were then divided into positive and negative influences on the residency experience. The four themes include systems experience, clinical experience, didactic experience, and wellness.

CONCLUSION

Our study examined the impact of COVID-19 on residents' educational experiences. We found overall mixed responses with a slightly negative impact on residency education, wellness, and clinical rotations, while satisfaction with EM as a career choice was increased. Factors influencing this included systems, clinical, and didactic experiences as well as overall wellness.

Worsening of emergency department length of stay during the COVID-19 pandemic

OBJECTIVE

Our study sought to determine whether there was a change in emergency department (ED) length of stay (LOS) during the coronavirus disease 2019 (COVID-19) pandemic compared to prior years.

METHODS

We performed a retrospective analysis using ED performance data 2018-2020 from 56 EDs across the United States. We used a generalized estimating equation (GEE) model to assess differences in ED LOS for admitted (LOS-A) and discharged (LOS-D) patients during the COVID-19 pandemic period compared to prior years.

RESULTS

GEE modeling showed that LOS-A and LOS-D were significantly higher during the COVID-19 period compared to the pre-COVID-19 period. LOS-A during the COVID-19 period was 10.3% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 28 minutes. LOS-D during the COVID-19 period was 2.8% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 2 minutes.

CONCLUSIONS

ED LOS-A and LOS-D were significantly higher in the COVID-19 period compared to the pre-COVID-19 period despite a lower volume of patients in the COVID-19 period.

Impact of the COVID-19 pandemic on radiology department emergency ultrasound utilization

Purpose

To analyze the change in utilization of healthcare resources through a review of ultrasound examinations performed in the emergency department of an urban healthcare system in NYC during the time of peak COVID-19 outbreak.

Methods

This is a retrospective review analyzing ED ultrasound exams performed by the radiology department of an urban healthcare system during the 8-week time period of the peak COVID-19 outbreak in NYC, compared to a time-matched period one year prior. Data regarding the examination type and indication were obtained in addition to patient demographics and indicators of outcomes including admission, length of stay, and mortality.

Results

There was a 58% decrease in ED ultrasounds performed by the radiology department during the COVID-19 time period. Exams performed during the pandemic compared to the pre-pandemic period were more likely to be performed on men (28.3 vs 18.0%, p < 0.01), older patients (36 vs. 35 years, p = 0.02), and patients subsequently admitted (17.8 vs. 13.4%, p = 0.03). There was also a difference in the distribution of exam type (p = 0.01). There was no difference in death, rate of surgery/intervention performed, or distribution of clinical indication. When correcting for gender, there was only an increase in studies leading to hospital admission in the female-only group (14.9 vs. 10.7%, p = 0.05).

Conclusion

COVID-19 had a drastic impact on the utilization of emergency department ultrasounds performed by the radiology department, with a decrease in total exams performed and changes in patient demographics, including a higher proportion of male patients and increases in some markers of disease severity, including rate of hospital admission.

Impact of national lockdown towards emergency department visits and admission rates during the COVID-19 pandemic in Thailand: A hospital-based study

OBJECTIVE

To evaluate the impact of the national lockdown because of the 2019 coronavirus (COVID-19) pandemic towards the ED visits and admission rates in Thailand.

METHODS

We retrospectively reviewed the electronic medical database of patients presenting to the ED during the national lockdown period (from 26 March to 30 June 2020). We used the same time interval in the year 2019 as the control period in our analysis. We collected baseline characteristics and outcomes of each patient in the ED. The primary outcome was the incidence rate ratio (IRR) with a 95% confidence interval (CI) of the average daily ED visits. Secondary outcomes included the IRR with 95% CI of total admissions and intensive care unit (ICU) admissions.

RESULTS

The average number of daily ED visits decreased significantly from 89.1 to 57.0 (-36.0%, IRR 0.69, 95% CI 0.67-0.70). However, the proportions of 'Resuscitation' and 'Emergency' triage level were increased (29.1% vs 19.2%, P < 0.001). Total ED admission rate and ICU admission rate were also increased (33.5% vs 28.3%, P < 0.001 and 10.2% vs 7.5%, P < 0.001, respectively). The IRR for the admission rate was 1.18 (95% CI 1.11-1.26), and the IRR for the ICU admission rate was 1.35 (95% CI 1.21-1.52).

CONCLUSION

The national lockdown in Thailand was associated with a significant reduction in average daily ED visits across traumatic and non-traumatic patients. Communication from healthcare professionals and public health officers is necessary to reinforce the importance of timely ED visits for acute health conditions.

Effect of the COVID-19 pandemic on CT scans ordered from the emergency department for abdominal complaints

Purpose

The COVID-19 pandemic has affected healthcare systems and patients alike across the USA. We seek to elucidate changes in abdominal imaging ordered from the emergency department (ED) in a healthcare system undergoing non-surge conditions in April 2020 compared to April 2019.

Methods

We performed a retrospective, observational study comparing patients undergoing CT scans of the abdomen and pelvis ordered from the ED in April 2020 vs. April 2019 at a single healthcare center. Via review of the radiology report and electronic medical record, we determined the positive or negative status of these scans. We evaluated percentages of positive CT scans and differences in outcomes, including admission rates, interventions, and mortality.

Results

Comparing 2020 to 2019, there was a 31.6% decrease in the number of CT scans performed from the ED. We found a higher percentage of positive CT findings, 58.2% vs. 50.8% (p = 0.025), and increased admission rates, 40.8% vs. 34.1% (p = 0.036). Differences were found in rates of appendicitis, colitis, and cholangitis. No difference was found in ICU admissions, interventions, or in-hospital mortality.

Conclusion

During the COVID-19 pandemic in a region undergoing non-surge conditions, we found increased rates of positive CT scans performed from the ED for abdominal complaints with an increased percentage of hospital admissions compared to a control year. No differences in ICU admissions or rates of procedural intervention were found to suggest higher acuity of pathology on presentation. Our findings suggest appropriately decreased healthcare utilization in our study period, driven by pre-hospital patient self-selection.

The Challenging Case Conference: A Gamified Approach to Clinical Reasoning in the Video Conference Era

The development of clinical reasoning abilities is a core competency of emergency medicine (EM) resident education and has historically been accomplished through case conferences and clinical learning. The advent of the SARS-CoV-2 pandemic has fundamentally changed these traditional learning opportunities by causing a nationwide reliance on virtual education environments and reducing the clinical diversity of cases encountered by EM trainees.

We propose an innovative case conference that combines low-fidelity simulation with elements of gamification to foster the development of clinical reasoning skills and increase engagement among trainees during a virtual conference. After a team of residents submits a real clinical case that challenged their clinical reasoning abilities, a different team of residents “plays” through a gamified, simulated version of the case live on a video conference call. The case concludes with a facilitated debriefing led by a simulation-trained faculty, where both the resident teams and live virtual audience discuss the challenges of the case. Participants described how the Challenging Case Conference improved their perceptions of their clinical reasoning skills. Audience members reported increased engagement compared to traditional conferences. Participants also reported an unexpected, destigmatizing effect on the discussion of medical errors produced by this exercise. Residency programs could consider implementing a similar case conference as a component of their conference curriculum.