Changes in emergency service access after spread of COVID-19 across Italy

The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review

BACKGROUND

Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy.

METHODS

A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19.

RESULTS

Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine.

CONCLUSIONS

Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.

Patient attendance at a pediatric emergency referral hospital in an area with low COVID-19 incidence

The purpose of this study was to clarify the effects of individual infection control measures and physical distancing on pediatric medical care in a local prefecture in Japan, where the incidence of coronavirus disease (COVID-19) in pediatric patients was extremely low. We extracted data from hospital records on the number of outpatients, inpatients, infectious disease consultations, and consultations for representative pediatric diseases. We compared attendance in 2017–2019, before the COVID-19 pandemic, with 2020, when COVID-19 spread to Japan. There were no COVID-19 patients in the pediatric department during the study period. The total number outpatient visits decreased by 24.4%, and the number of hospital admissions, excluding neonatal care unit admissions, decreased by approximately 35%. There was a marked reduction in the number of hospitalizations for infectious diseases such as influenza (−74.8%) and respiratory syncytial virus infection (−93.5%), and the number of hospitalizations for bronchitis/pneumonia, Kawasaki disease, and bronchial asthma decreased. In contrast, the number of clinical psychological interventions and cases reported to the child guidance center increased. In the context of pandemic infectious diseases, it is important to control the spread of problematic infectious diseases by individual infection control measures and physical distancing. However, it is necessary to maintain social life as much as possible for the mental health and physical development of children.

Go Greener, Less Risk: Access to Nature Is Associated with Lower Risk Taking in Different Domains during the COVID-19 Lockdown

Specific risk attitude and risky behavior had an important boost during the coronavirus disease 2019 (COVID-19) pandemic. In this contribution, we hypothesize that access to nature during home confinement will decrease both the tendency to passive risk taking and alcohol intake. To do so, we interviewed through an online survey two samples of Italian residents during the strict lockdown due to the first wave of the COVID-19 pandemic. Specifically, in Study 1, participants were 1519 Italian residents coming from different Italian regions, whilst in Study 2, participants were 182 students at a university of southern Italy who were monitored for one week. In Study 1, the hierarchical regression analysis attested that access to nature during the lockdown mitigated the tendency to passive risk taking, over and beyond the effect of socio-demographic variables and the psychological construct of impulsiveness, an important personality correlate of risk taking. In Study 2, the hierarchical regression showed that access to green was associated with fewer glasses of alcohol drunk in a week of lockdown. This effect held over and above the effect of socio-demographic variables and the drinking behavior before the outbreak of the COVID-19 pandemic. In both studies, findings confirmed the beneficial effect of access to nature in specific risk-taking domains. Theoretical future directions, as well as practical implications for the management of the COVID-19 emergency by policymakers, are discussed.

Impact of the coronavirus pandemic on mental health and health care in adults with neurofibromatosis: Patient perspectives from an online survey

The coronavirus pandemic increased anxiety and stress and prevented access to health care worldwide; it is unclear how COVID-19 affected adults with a multisystem genetic disorder such as neurofibromatosis (NF). An anonymous online survey was distributed through an international registry and foundations to adults with NF (June-August 2020) to assess the impact of the pandemic on mental health and NF health care. Six hundred and thirteen adults (18-81 years; M = 45.7) with NF1 (77.8%), NF2 (14.2%), and schwannomatosis (7.8%) provided complete responses. Respondents rated moderate-to-high amounts of worry about the impact of COVID-19 on their emotional (46.3%) and physical health (46.7%), and 54.8% endorsed moderate-to-high pandemic-related stress. Adults with diagnosed/suspected mental health disorders or moderate-to-severe NF symptom impact as well as females endorsed higher COVID-19 stress (ps < 0.01). Less than half who missed a doctor's appointment for their NF care (43.4%) used telehealth. Of these, 33.3% and 46.2% reported that telehealth met their needs to a moderate or high degree, respectively. Results indicated that subgroups of adults with NF experience higher COVID-19-related worries and stress and may need additional support. Furthermore, telehealth is under-utilized and could help NF providers connect with patients, although improved delivery and patient training may facilitate expanded use of these services.

Repercussions of covid-19-related national lockdown on emergency surgery department: a longitudinal cohort monocentric study

BACKGROUND

COVID-19 lockdown restrictions in conjunction with the pervasive hospital fear endured by the vast majority of the population played a fundamental role in discouraging access to emergency departments (EDs). We aimed at investigating whether and how the COVID-19 outbreak limited access to ED and affected urgent surgical activities during and immediately after the 2-month pandemic-related national lockdown.

METHODS

Data regarding patients who accessed to the surgical ED were retrospectively collected. Analysed time-periods included: 'Pre-COVID-19 Era', 'COVID-19 Era' considered as the period of full national lockdown and 'Post-COVID-19 Era' after easing of lockdown measures. Consecutive emergency surgical procedures and ED admissions before, during and after COVID-19-lockdown were retrieved and analysed.

RESULTS

There was a significant decrease in overall ED admissions and in all-specialty surgical consultations (P<0.01) throughout the outbreak. Once national lockdown was eased, we recorded a subsequent rebound 5-fold rise of emergency surgical procedures compared to COVID-19 group (P=0.011). Time-to-surgery was significantly greater in 'COVID-19 era' and 'post-COVID-19 era' compared to 'pre-COVID-19' group (22.56±4.78, 75.99±15.89 and 16.73 ±1.76 hours, respectively) (P<0.01). A raised incidence of postoperative complications emerged in the 'COVID-19 era' group (37.5%) compared to pre and post-COVID groups (9.1% and 12.5%, respectively; P<0.001). Mortality rate in the 'COVID-19 era' was 31.3% and 7.5% in 'post-COVID-19' group (<0.0001).

CONCLUSIONS

This study demonstrates the major reduction of emergency surgical procedures and overall ED admissions caused by COVID-19 pandemic. The raised rate of postoperative complications and mortality might be likely due to the superior severity of surgical conditions observed in the 'COVID-19 era' subjects together with a probable deferred pursuit of medical attention.

Non-COVID-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in Northern Italy

The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare needs. Not exhaustive data are available on the consequences of this on non-COVID-19 patients. The aim of this study was to assess the impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants' area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year. Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of ED visits was observed in all age groups and across all severity and diagnosis groups. In the lockdown period a significant increase was found in overall out-of-hospital mortality (43.2%) and cause-specific out-of-hospital mortality related to neoplasms (76.7%), endocrine, nutritional and metabolic (79.5%) as well as cardiovascular (32.7%) diseases. The pandemic caused a sudden drop of ED visits and hospitalizations of non-COVID-19 patients during the lockdown period, and a concurrent increase in out-of-hospital mortality mainly driven by deaths for neoplasms, cardiovascular and endocrine diseases. As recurrencies of the COVID-19 pandemic are underway, the scenario described in this study might be useful to understand both the population reaction and the healthcare system response at the early phases of the pandemic in terms of reduced demand of care and systems capability in intercepting it.

Considerations for diagnostic COVID-19 tests

During the early phase of the coronavirus disease 2019 (COVID-19) pandemic, design, development, validation, verification and implementation of diagnostic tests were actively addressed by a large number of diagnostic test manufacturers. Hundreds of molecular tests and immunoassays were rapidly developed, albeit many still await clinical validation and formal approval. In this Review, we summarize the crucial role of diagnostic tests during the first global wave of COVID-19. We explore the technical and implementation problems encountered during this early phase in the pandemic, and try to define future directions for the progressive and better use of (syndromic) diagnostics during a possible resurgence of COVID-19 in future global waves or regional outbreaks. Continuous global improvement in diagnostic test preparedness is essential for more rapid detection of patients, possibly at the point of care, and for optimized prevention and treatment, in both industrialized countries and low-resource settings.

Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system

Background

Reports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes.

Methods

For this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted.

Results

A total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207).

Discussion

Early phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation.

Level of evidence

Level II (therapeutic/care management).

COVID-19 lock-down significantly reduced number of surgical presentations in an emergency department

Background

Coronavirus disease 2019 (COVID-19) is an acute virus infection, which was declared by the World Health Organization (WHO) as a pandemic. As a consequence, the Swiss government decreed a public lock-down to reduce and restrict further infections. The aim of this investigation was to provide the impact of the COVID-19 lock-down on the presentations of patients in an interdisciplinary emergency department (ED).

Patients, material and methods

A retrospective study was performed at an interdisciplinary Swiss ED during the lock-down period. All patients who presented to the ED were enrolled in this investigation and compared to a control cohort during the same time period in 2019. Data regarding patients’ characteristics, medical specialty, time course of presentations during the observation period, outpatient or hospital admission were analyzed.

Results

In total 7072 patients were included in the final analysis. During the lock-down period the number of ED presentations significantly decreased by 29% in comparison to the control period in the previous year (p < 0.0001). The analysis of the time course revealed that in each week the number of patients was lower with 13–43% reduction. Irrespective of the medical specialty, the number of presentations decreased during the COVID-19 situation, whereas this decrease was higher in surgical diseases (31%, p < 0.0001) than in non-surgical presentations (3.6%, p = 0.4).

Conclusion

The socioeconomic lock-down was associated with reduced number of presentations in an ED. Mainly, surgical diseases and injuries were affected in terms of a reduction of presentations during the COVID-19 lock-down period.

Doubled mortality rate during the COVID-19 pandemic in Italy: quantifying what is not captured by surveillance

Objectives

It is important to quantify the true burden of coronavirus disease 2019 (COVID-19) in different countries, to enable informed decisions about imposing and relaxing control measures. COVID-19 surveillance data fails in this respect, as it is influenced by different definitions, control policies and capacities. This article aims to quantify excess mortality and estimate the distribution between COVID-19 and non-COVID-19 causes of death.

Study design

Observational study and mathematical modelling.

Methods

Publicly available data from multiple institutional sources were used and an in-depth analysis was carried out of deaths from all causes between 2015 and 2020 in Italy at the national, regional and local level. Excess mortality over time and space was first explored, followed by an assessment of how this related to COVID-19 surveillance and, ultimately, assuming a fixed male:female ratio, a model was developed and applied to estimate the proportions of COVID-19 and non-COVID-19 excess mortality in 2020.

Results

In Italy, the mortality rate doubled in March and April 2020 compared with data from 2015 to 2019 (+109%, when considering municipalites with >10.000 inhabitants), with excess mortality reaching >600% in large municipalities in northern areas. Notified COVID-19 deaths accounted for only 43.5% (regional range: 43–62%) of excess mortality. It is estimated that more than two-thirds of excess deaths that were not captured by surveillance are non-COVID-19 deaths, which could be a result of the excess burden on the health systems, in addition to reduced demand and supply of other non-COVID healthcare services.

Conclusions

The impact of COVID-19 during the early stages of the pandemic is much larger than official figures have reported. Monitoring excess mortality helps to capture the full effect of the COVID-19 pandemic, which differs between regions in Italy and which might have resulted in significant indirect effects on the well-being of the population. In addition, the COVID-19 pandemic has also resulted in significant indirect effects on the well-being of the population.

COVID-19 related reduction in pediatric emergency healthcare utilization - a concerning trend

Background

The COVID-19 pandemic has disrupted healthcare systems worldwide. In addition to the direct impact of the virus on patient morbidity and mortality, the effect of lockdown strategies on health and healthcare utilization have become apparent. Little is known on the effect of the pandemic on pediatric and adolescent medicine. We examined the impact of the pandemic on pediatric emergency healthcare utilization.

Methods

We conducted a monocentric, retrospective analysis of n = 5,424 pediatric emergency department visits between January 1st and April 19th of 2019 and 2020, and compared healthcare utilization during the pandemic in 2020 to the same period in 2019.

Results

In the four weeks after lockdown in Germany began, we observed a massive drop of 63.8% in pediatric emergency healthcare utilization (mean daily visits 26.8 ± SEM 1.5 in 2019 vs. 9.7 ± SEM 1 in 2020, p < 0.005). This drop in cases occurred for both communicable and non-communicable diseases. A larger proportion of patients under one year old (daily mean of 16.6% ±SEM 1.4 in 2019 vs. 23.1% ±SEM 1.7 in 2020, p < 0.01) and of cases requiring hospitalisation (mean of 13.9% ±SEM 1.6 in 2019 vs. 26.6% ±SEM 3.3 in 2020, p < 0.001) occurred during the pandemic. During the analysed time periods, few intensive care admissions and no fatalities occurred.

Conclusions

Our data illustrate a significant decrease in pediatric emergency department visits during the COVID-19 pandemic. Public outreach is needed to encourage parents and guardians to seek medical attention for pediatric emergencies in spite of the pandemic.