Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia

Review article: Telehealth in Emergency Medicine in Australasia: Advantages and barriers

The COVID-19 pandemic catapulted Telehealth to the forefront of Emergency Medicine (EM) as an alternative way of assessing and managing patients. This challenged the traditional idea that EM can only be practised within brick-and-mortar EDs. Many Emergency Physicians may find the idea of practising Telehealth in Emergency Medicine (TEM) confronting, particularly in the absence of training and clear practice guidelines. The purpose of the present paper is to describe the current use of TEM in Australasia, and outline the advantages and barriers in adopting this practice domain.

Factors predictive of hospital admission for children via emergency departments in Australia and Sweden: an observational cross-sectional study

BACKGROUND

Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden.

METHODS

A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission.

RESULTS

Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately.

CONCLUSIONS

Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

Impact of COVID-19 state-wide lockdown on older adult presentations to Queensland emergency departments

OBJECTIVE

To determine the impact of the COVID-19 state-wide lockdown on ED presentations for older adults in Queensland, Australia.

METHODS

A retrospective cohort study pertaining to adults aged 70+ years who presented to Queensland public hospital EDs across three separate time periods; 11 March to 30 June 2018 and 2019 (pre-pandemic average), 2020 (COVID-19 state-wide lockdown) and 2021 (post-state-wide lockdown). The primary outcome was change in presentation rates to ED. Secondary outcomes included change in triage category rates, length of stay (LOS), diagnosis and disposition.

RESULTS

There was 380 854 older adult presentations. During the COVID-19 state-wide lockdown, ED presentation rates decreased by 12.5% (incidence rate ratio 0.875 [95% confidence interval 0.867-0.883]). All triage category presentation rates decreased, as did ED LOS and reasons for presentation, except sepsis and disorders of the nervous system. In the post-state-wide lockdown period a 22% (incidence rate ratio 1.22 [95% confidence interval 1.21-1.23]) increase in the presentation rate was observed and presentations in all triage categories increased. ED LOS increased to longer than pre-pandemic (P < 0.001). Respiratory presentations increased by 346%. Patients who 'did not wait' increased by 212% and ED mortality rose by 42% compared to during the lockdown.

CONCLUSION

There was a significant decrease in presentation rates to EDs during the COVID-19 state-wide lockdown for the older population, followed by an increase in presentation rates, longer ED LOS, and an increased ED mortality rate, in the post-state-wide lockdown period. It is important to ensure older adults continue to seek appropriate, timely medical care, during a pandemic.

The Impact of the Second Wave of the COVID-19 Pandemic on Non-COVID Hospital Care in a Tertiary Hospital in Spain

In 2020, Spain ranked fourth among European countries with the highest excess mortality due to COVID-19 disease. This study evaluates the impact of the COVID-19 pandemic on non-COVID patients in a tertiary hospital during the second pandemic wave in Spain (22 June 2020-6 December 2020). Data from Virgen del Rocío University Hospital in Seville during that timeframe were compared with the data from the same period in the preceding two years (2018-2019). Between-group comparisons were performed using the Chi-squared test, Student's t-test, or Mann-Whitney U tests, as appropriate. A total of 63,137 non-COVID patients were included in this study. During the second pandemic wave, a 19% decrease was observed in the annual number of non-COVID admissions overall (18,260 vs. 22,439, p < 0.001), but a 10% increase in the proportion of emergency admissions (60.6% vs. 54.93%, p < 0.001), a higher severity level of patients (1.79 vs. 1.72, p < 0.001), a longer in-hospital stay (7.02 vs. 6.74 days, p < 0.001), a 26% increase in non-COVID mortality (4.9% vs. 3.9%, p < 0.001), and a 50% increase in global mortality (5.9 vs. 3.9, p < 0.001) were also observed. In terms of both medical and surgical diagnoses, a significant reduction in the number of admissions and an increase in in-hospital mortality were observed. These results demonstrate the significant impact of the pandemic on hospital care, similar to what was previously observed during the initial wave in the same hospital. Our findings emphasize the need to include non-COVID patients when assessing the broad impact of the pandemic on healthcare, beyond its direct effects on COVID-19 patients.

Changes in opioid and other analgesic prescribing following voluntary and mandatory prescription drug monitoring program implementation: A time series analysis of early outcomes

BACKGROUND

Australian prescription drug monitoring programs (PDMPs) provide information about a patient's recent medication history for controlled drugs at the point of prescribing and dispensing. Despite their increasing use, the evidence for PDMPs is mixed, and is almost exclusively from the United States. This study examined the impact of PDMP implementation on opioid prescribing among general practitioners in Victoria, Australia.

METHOD

We examined data on analgesic prescribing using electronic records of 464 medical practices in the Australian state of Victoria between 01/04/2017 and 31/12/ 2020. We used interrupted time series analyses, to examine immediate and longer-term trends in medication prescribing following voluntary (from April 2019) and mandatory PDMP implementation (from April 2020). We examined changes in three outcomes (i) 'high' opioid dose (50-100mg oral morphine equivalent daily dose (OMEDD) and over 100mg (OMEDD) prescribing (ii) prescribing of high-risk medication combinations (opioids with either benzodiazepines or pregabalin), and (iii) initiation of non-controlled pain medications (tricyclic antidepressants, pregabalin and tramadol).

RESULTS

We found no effect of voluntary or mandatory PDMP implementation on 'high-dose' opioid prescribing with reductions only seen in those prescribed <20mg OMEDD (i.e., the lowest dose category). Co-prescribing of opioids with benzodiazepines (additional 11.87 [95%CI 2.04 to 21.67] patients/10,000 and pregabalin (additional 3.54 [95% CI 0.82 to 6.26] patients/10,000 increased following mandatory PDMP implementation among those prescribed opioids. In contrast to trends of reduced initiation prior to PDMP implementation, we found increased new initiation of non-monitored medications following PDMP implementation (e.g., an immediate increase of 2.32 [95%CI 0.02 to 4.54], patients/10,000 received pregabalin and 3.06 [95%CI 0.54 to 5.5] patients/10,000 received tricyclic antidepressants after mandatory PDMP implementation), and increased tramadol initiation during the voluntary PDMP period (an increase of 11.26 [95%CI: 5.84, 16.67] patients /10,000).

CONCLUSION

PDMP implementation did not appear to reduce prescribing of high opioid doses or high-risk combinations. Increased initiation of tricyclic antidepressants, pregabalin and tramadol may indicate a possible unintended effect.

Emergency department presentations during the COVID-19 pandemic in Queensland (to June 2021): interrupted time series analysis

OBJECTIVES

To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers.

DESIGN

Interrupted time series analysis.

SETTING

All 105 Queensland public hospital EDs.

MAIN OUTCOME MEASURES

Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers).

RESULTS

During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12-month post-lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis.

CONCLUSIONS

The COVID-19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs.

Is this child suitable to be seen in primary care? Poor agreement between caregiver/family perception and definitions of a 'primary care-type' patient

AIMS

To compare and evaluate the number of paediatric patients classified as 'suitable for primary care' using the Australian Institute of Health and Welfare (AIHW) method, the Australasian College for Emergency Medicine (ACEM) method, and parental judgement.

METHODS

This was a prospective observational study enrolling parents/carers presenting with their children to two Victorian EDs in Victoria, Australia over a 1-week period. Trained research assistants were posted within both EDs and surveyed all eligible parents/carers whether they agreed with the statement 'I think a GP would be able to look after my child's current illness/injury'. Survey responses were linked to clinical outcomes and length of stay. Each presentation was classified as suitable for primary care using the AIHW method, the ACEM method and parental survey. Agreement between definitions was assessed using Cohen's kappa statistic.

RESULTS

During the study (June 2016), 1069 patients presented to the two EDs; 677 patients were able to be classified under all three definitions (AIHW: 1069, ACEM: 991, survey: 677 patients). Only 80/677 (12%) patients met all three criteria. Agreement was slight between the parent survey and the ACEM method (K = 0.14, 95% confidence interval (CI) 0.06-0.21), and the parent survey and the AIHW method (K = 0.12, 95% CI 0.05-0.19). There was moderate agreement between the ACEM and AIHW methods (K = 0.45, 95% CI 0.39-0.51).

CONCLUSIONS

There is very poor agreement on what defines a 'primary care-type' paediatric patient between the definitions used by government, professional bodies and caregivers.

Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction?

Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.

Healthcare Avoidance before and during the COVID-19 Pandemic among Australian Youth: A Longitudinal Study

Background: Access to healthcare for young people is essential to ensure they can build a foundation for a healthy life. However, during the COVID-19 pandemic, many people avoided seeking healthcare, adversely affecting population health. We investigated the factors associated with the avoidance of healthcare for Australian young people when they reported that they needed healthcare. We were able to compare healthcare avoidance during the COVID-19 pandemic with healthcare avoidance prior to COVID-19. Methods: We used two recent data collection waves from the Longitudinal Study of Australian Children (LSAC)—Wave 9C1 during the COVID-19 pandemic in 2020, and Wave 8 data which were collected in 2018. The primary outcome of this study revealed the avoidance of healthcare among those who perceived the need for care. Bivariate analyses and multiple logistic regression models were employed to identify the factors associated with the avoidance of healthcare during the COVID-19 and pre-COVID-19 periods. Results: In the sample of 1110 young people, 39.6% avoided healthcare during the first year of the COVID-19 pandemic even though they perceived that they had a health problem that required healthcare. This healthcare avoidance was similar to the healthcare avoidance in the pre-COVID-19 pandemic period (41.4%). The factors most strongly associated with healthcare avoidance during the COVID-19 pandemic were female gender, an ongoing medical condition, and moderately high psychological distress. In comparison, prior to the pandemic, the factor associated with healthcare avoidance was only psychological distress. The most common reason for not seeking healthcare was thinking that the problem would spontaneously resolve itself (55.9% during COVID-19 vs. 35.7% pre-COVID-19 pandemic). Conclusions: A large proportion of youths avoided healthcare when they felt they needed to seek care, both during and before the COVID-19 pandemic.