Elderly People's Access to Emergency Departments during the COVID-19 Pandemic: Results from a Large Population-Based Study in Italy

Traumatic brain injury incidence and mortality: a large population-based study

BACKGROUND

Traumatic brain injury (TBI) is a severe condition that represents a major global public health concern.

OBJECTIVES

Provide a comprehensive epidemiological outlook encompassing TBI incidence, healthcare provision and mortality.

METHODS

Population-based study in Veneto (4.9 million inhabitants), Italy, from 2012 to 2021. Hospital discharge and mortality records were used to assess incidence and mortality. Kaplan-Meier survival estimator and Cox regression models were fitted to investigate determinants of mortality.

RESULTS

Between 2012 and 2021, there were 37,487 incident TBI cases, corresponding to an age-standardized rate of 77.30/100,000 people (95% CI 76.52-78.09), higher among males, with an exponential growth after age 70. Leading causes were domestic (33.1%) and traffic accidents (17.7%), the first predominating among the elderly and children, while the latter in males 15-24 and older people. After rates stably declined between 2012 and 2019, the study captured a sharp decrease especially for traffic and occupational accidents in males, due to COVID-19 lockdown in 2020. Overall, 48.9% TBI patients were hospitalized in a specialized trauma center, with 2.6% requiring a transfer after accessing a spoke hospital. Over a 3.7 years median follow-up, 16,145 deaths were recorded, with higher mortality for those undergoing neurosurgical interventions, regardless of their access point. Risks of death increased with age, male gender, and comorbidities.

DISCUSSION

TBI incidence is characterized by distinct patterns, affecting particularly older individuals and males. Minimal hospital transfers with comparable survival irrespective of access point suggests an effective patient management within the network. The study underscores the critical need for acute-phase support and prolonged care strategies for older TBI patients.

Effects of coronavirus disease 2019 on the spread of respiratory-transmitted human-to-human bacteria

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has necessitated significant changes in medical systems, social behaviours, and non-pharmaceutical interventions (NPIs). We aimed to determine the effect of the COVID-19 pandemic on changes in the epidemiology of respiratory-transmitted bacteria that have been unexplored.

METHODS

We utilised a comprehensive national surveillance database from 2018 to 2021 to compare monthly number of patients with four respiratory-transmitted human-to-human bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) before and after the COVID-19 pandemic, stratified by specimen sources and age groups.

RESULTS

The incidence of detected patients with S. pneumoniae, H. influenzae, and S. pyogenes from both respiratory and blood cultures significantly decreased from 2019 to 2020. In 2021, the incidence of detected patients with the respiratory-transmitted bacterial species, except for S. pyogenes, from respiratory cultures, increased again from April to July, primarily affecting the 0-4-year age group.

CONCLUSIONS

Our comprehensive national surveillance data analysis demonstrates the dynamic changes and effects of NPIs on respiratory-transmitted bacteria during the COVID-19 pandemic, with variations observed among species, specimen sources, and age groups.

Vascular service provision during the COVID-19 pandemic worsened major amputation rates in socially deprived diabetic populations

Introduction

The Coronavirus Disease - 2019 (COVID-19) pandemic significantly impacted healthcare service provision and put diabetic patients at increased risk of adverse health outcomes. We aimed to assess the impact of the COVID-19 pandemic on the incidence and demographic shift of major lower-limb amputation in diabetic patients.

Methods

We performed a retrospective analysis of diabetic patient records undergoing major lower-limb amputation between 01/03/2019 and 01/03/2021 at the Royal Sussex County Hospital, the regional arterial hub for Sussex. Primary outcomes were amputation incidence rates and patient demographics compared between the prepandemic and pandemic cohorts.

Results

The incidence rate ratio of major lower-limb amputations shows a drop in amputations during the pandemic compared to pre-pandemic (IRR 0.82; 95% CI 0.57-1.18). Data suggests a shift in the social deprivation background of patients receiving amputations to disproportionately affect those in the more deprived 50% of the population (p=0.038). Younger patients received more amputations during the pandemic compared to prepandemic levels (p=0.001).

Conclusion

Results suggest that during the COVID-19 pandemic there was a paradoxical reduction in amputations compared to prepandemic levels. However, changes to the demographic makeup of patient's receiving amputations are alarming as younger, and more deprived patients have been disproportionately affected by the pandemic.

Effect of the COVID-19 pandemic on utilization of essential health services in Iran evidence from an interrupted time series analysis

BACKGROUND

The COVID-19 disrupted the provision of essential health services in numerous countries, potentially leading to outbreaks of deadly diseases. This study aims to investigate the effect of the COVID-19 pandemic on the utilization of essential health services in Iran.

METHODS

An analytical cross-sectional study was conducted using interrupted time series (ITS) analysis. Data about five indicators, including 'childhood vaccination, infant care, hypertension screening, diabetes screening, and breast cancer screening,' were obtained from the electronic health record System in two-time intervals: 15 months before (November 2018 to January 2020) and 15 months after (January 2020 to May 2021) the onset of the COVID-19 pandemic. The data were analyzed by utilizing ITS. In addition, a Poisson model was employed due to the usage of count data. The Durbin-Watson (DW) test was used to identify the presence of lag-1 autocorrelation in the time series data. All statistical analysis was performed using R 4.3.1 software, considering a 5% significance level.

RESULTS

The ITS analysis showed that the COVID-19 pandemic significantly affected the utilization of all essential health services (P < 0.0001). The utilization of hypertension screening (RR = 0.51, p < 0.001), diabetes screening (RR = 0.884, p < 0.001), breast cancer screening (RR = 0.435, p < 0.001), childhood vaccination (IRR = 0.947, p < 0.001), and infant care (RR = 1.666, p < 0.001), exhibited a significant decrease in the short term following the pandemic (P < 0.0001). However, the long-term trend for all service utilization, except breast cancer screening (IRR = 0.952, p < 0.001), demonstrated a significant increase.

CONCLUSIONS

The COVID-19 pandemic affected utilization of essential health care in Iran. It is imperative to utilize this evidence to develop policies that will be translated into targeted planning and implementation to sustain provision and utilization of essential health services during public health emergencies. It is also vital to raise awareness and public knowledge regarding the consequences of interruptions in essential health services. In addition, it is important to identify the supply- and demand-side factors contributing to these disruptions.

The impact of the COVID-19 pandemic on frail older people ageing in place alone in two Italian cities: Functional limitations, care arrangements and available services

The study aimed to explore and compare effects of lockdown, due to the COVID-19 pandemic in 2020, on frail older people living alone at home in Brescia and Ancona, two urban cities located respectively in Northern and Central Italy. This country was the Western epicenter of the first wave of the pandemic (February-May 2020), which affected the two cities differently as for infections, with a more severe impact on the former. A follow-up study of the IN-AGE research project (2019) was carried out in July-September 2020, by means of telephone interviews, involving 41 respondents. Semi-structured questions focused on the effects of the first wave of the pandemic on their mobility and functional limitations, available care arrangements, and access to health services. The lockdown and social distancing measures overall negatively impacted on frail older people living alone, to a different extent in Ancona and Brescia, with a better resilience of home care services in Brescia, and a greater support from the family in Ancona, where however major problems in accessing health services also emerged. Even though the study was exploratory only, with a small sample that cannot be considered as representative of the population, and despite differences between the two cities, findings overall suggested that enhancing home care services, and supporting older people in accessing health services, could allow ageing in place, especially in emergency times.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Outcome of emergency patients transported by ambulance during the COVID-19 pandemic in Osaka Prefecture, Japan: a population-based descriptive study

Background

The novel corona virus (COVID-19) pandemic occurred worldwide. Although an excessive burden was placed on emergency medical institutions treating urgent and severe patients, its impact on patient outcome remains unknown. This study aimed to assess the impact of the COVID-19 pandemic in 2021 on the emergency medical services (EMS) system and patient outcomes in Osaka Prefecture, Japan.

Methods

This was a retrospective descriptive study with a study period from January 1, 2019 to December 31, 2021. We included patients who were transported by ambulance and had cleaned data that was recorded in the ORION system. The study endpoints were the number of patients transported by ambulance and the number of deaths among these patients in each month. To assess the impact of the COVID-19 pandemic on the EMS system, the incidence rate ratio (IRR) and 95% confidence interval (CI) were calculated using 2019 as the reference year. Mortalities were evaluated based on deaths in the emergency department and deaths at 21 days after hospitalization.

Results

The numbers of patients transported by ambulance were 500,194 in 2019, 443,321 in 2020 (IRR: 0.88, 95% CI: 0.87-0.88), and 448,054 in 2021 (IRR: 0.90, 95% CI: 0.89-0.90). In 2019, the number of patients transported by ambulance and who died in the emergency departments was 4,980, compared to 5,485 in 2020 (IRR: 1.10, 95% CI; 1.06-1.44) and 5,925 in 2021 (IRR: 1.19, 95% CI: 1.15-1.24). In 2019, the number of patients who died within 21 days after hospitalization was 11,931, compared to 11,913 in 2020 (IRR; 1.00, 95% CI; 0.98-1.03) and 13,376 in 2021 (IRR; 1.12, 95% CI; 1.09-1.15).

Conclusion

The COVID-19 pandemic decreased the number of ambulance requests and worsened mortality of patients transported by ambulance in Osaka Prefecture during 2021.

Impact of COVID-19 on hospital visits for non-traumatic dental conditions in Ontario, Canada

BACKGROUND AND RATIONALE

As general health care is publicly funded in Canada and oral health care is not, many people seek care from hospitals for their dental problems. This study assessed if the unprecedented times of Coronavirus disease (COVID-19) affected the hospital visits for dental emergencies, making disadvantaged populations further vulnerable for attendance of their dental problems.

METHODS

Data from IntelliHealth Ontario for emergency department (ED) visits, day surgery visits, and hospitalizations associated with non-traumatic dental conditions (NTDCs) were retrieved for years 2016 to 2020 to assess trends before COVID-19 and changes, if any, for the year 2020. Trends by month, for the years 2019 and 2020, to make straight comparisons and understand the effects of lockdown in Ontario, was also analyzed.

RESULTS

In the year 2020, there was a reduction of 40% in day surgeries, 21% in ED visits and 8% in hospitalizations compared to 2019. Stratified by month, largest reductions were observed in April 2020: 96% in day surgeries; 50% in ED visits; and 38% reductions in hospitalizations when compared to the same month of 2019. In May 2020, day surgeries and ED visits though remained reduced, hospitalization rates increased by 31%.

CONCLUSION

Hospital EDs are inefficient avenues for handling dental emergencies. Nevertheless, they do remain a care setting that is sought by many for dental problems, and if the need for hospitalization and day surgery is there, this care setting is an important avenue for dentally related medical care. Perhaps unsurprisingly, COVID-19 has lessened the opportunity and capacity for such care.

PRACTICAL IMPLICATIONS

Administrators and policy makers can utilize this information to strategize on augmenting community infrastructure for building more effective, and cost-efficient avenues of care for timely management of dental problems.

The Geras virtual frailty rehabilitation program to build resilience in older adults with frailty during COVID-19: a randomized feasibility trial

BACKGROUND

The Coronavirus (COVID-19) pandemic has exacerbated the risk for poor physical and mental health outcomes among vulnerable older adults. Multicomponent interventions could potentially prevent or reduce the risk of becoming frail; however, there is limited evidence about utilizing alternative modes of delivery where access to in-person care may be challenging. This randomized feasibility trial aimed to understand how a multicomponent rehabilitation program can be delivered remotely to vulnerable older adults with frailty during the pandemic.

METHODS

Participants were randomized to either a multimodal or socialization arm. Over a 12-week intervention period, the multimodal group received virtual care at home, which included twice-weekly exercise in small group physiotherapy-led live-streamed sessions, nutrition counselling and protein supplementation, medication consultation via a videoconference app, and once-weekly phone calls from student volunteers, while the socialization group received only once-weekly phone calls from the volunteers. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate the feasibility of the program. The main clinical outcomes were change in the 5-times sit-to-stand test (5 × STS) and Depression, Anxiety and Stress Scale (DASS-21) scores. The feasibility outcomes were analyzed using descriptive statistics and expressed as frequencies and mean percent with corresponding confidence intervals (CI). Analysis of covariance (ANCOVA) was used for the effectiveness component.

RESULTS

The program enrolled 33% (n = 72) of referrals to the study (n = 220), of whom 70 were randomized. Adoption rates from different referral sources were community self-referrals (60%), community organizations (33%), and healthcare providers (25%). At the provider level, implementation rates varied from 75 to 100% for different aspects of program delivery. Participant's adherence levels included virtual exercise sessions 81% (95% CI: 75-88%), home-based exercise 50% (95% CI: 38-62%), protein supplements consumption 68% (95% CI: 55-80%), and medication optimization 38% (95% CI: 21-59%). Most participants (85%) were satisfied with the program. There were no significant changes in clinical outcomes between the two arms.

CONCLUSION

The GERAS virtual frailty rehabilitation study for community-dwelling older adults living with frailty was feasible in terms of reach of participants, adoption across referral settings, adherence to implementation, and participant's intention to maintain the program. This program could be feasibly delivered to improve access to socially isolated older adults where barriers to in-person participation exist. However, trials with larger samples and longer follow-up are required to demonstrate effectiveness and sustained behavior change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04500366. Registered August 5, 2020, https://clinicaltrials.gov/ct2/show/NCT04500366.

Impact of the COVID-19 pandemic on medical-seeking behavior in older adults by comparing the presenting complaints of the emergency department visits

BACKGROUND

The outbreak of the coronavirus disease 2019 (COVID-19) has caused a catastrophic event worldwide. Since then, people's way of living has changed in terms of personal behavior, social interaction, and medical-seeking behavior, including change of the emergency department (ED) visiting patterns. The objective of this study was to analyze the impact of the COVID-19 pandemic on the ED visiting patterns of the older people to explore its variable expression with the intention of ameliorating an effective and suitable response to public health emergencies.

METHODS

This was a retrospective study conducted in three hospitals of the Cathay Health System in Taiwan. Patients aged ≥ 65 years who presented to the ED between January 21, 2020, and April 30, 2020 (pandemic stage), and between January 21, 2019, and April 30, 2019 (pre-pandemic stage) were enrolled in the study. Basic demographics, including visit characteristics, disposition, and chief complaints of the patients visiting the ED between these two periods of time, were compared and analyzed.

RESULTS

A total of 16,655 older people were included in this study. A 20.91% reduction in ED older adult patient visits was noted during the pandemic period. During the pandemic, there was a decrease in ambulance use among elderly patients visiting the ED, with the proportion decreasing from 16.90 to 16.58%. Chief complaints of fever, upper respiratory infections, psychological and social problems increased, with incidence risk ratios (IRRs) of 1.12, 1.23, 1.25, and 5.2, respectively. Meanwhile, the incidence of both non-life-threatening and life-threatening complaints decreased, with IRRs of 0.72 and 0.83, respectively.

CONCLUSION

Health education regarding life-threatening symptom signs among older adult patients and avocation of the proper timing to seek medical attention via ambulance were crucial issues during the pandemic.

Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study

BACKGROUND

This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients.

METHODS

We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS.

RESULTS

Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7-13.4) and CFS score (OR, 5.8; 95% CI, 1.9-17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS.

CONCLUSIONS

The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.

Treatment Patterns and Outcomes of Patients with Grade 4 Glioma Treated with Radiation during the COVID-19 Pandemic

During the first year of the COVID-19 pandemic there was a global disruption in the provision of healthcare. Grade 4 gliomas are rapidly progressive tumors, and these patients are at risk of poorer outcomes due to delays in diagnosis or treatment. We retrospectively evaluated the impact of the pandemic on treatment patterns and outcomes of patients with grade 4 gliomas in British Columbia. We identified a cohort of 85 patients treated with radiotherapy between March 2020–2021 (COVID era) and compared baseline characteristics, treatments, and outcomes with a control cohort of 79 patients treated between March 2018–2019 (pre-COVID era). There were fewer patients treated with radiotherapy over age 65 in the COVID era compared to the pre-COVID era (p = 0.037). Significantly more patients were managed with biopsy relative to partial or gross total resection during the COVID era compared to the pre-COVID era (p = 0.04), but there were no other significant differences in time to assessment, time to treatment, or administration of adjuvant therapy. There was no difference in overall survival between eras (p = 0.189). In this assessment of outcomes of grade 4 gliomas during the pandemic, we found that despite less aggressive surgical intervention during the COVID era, outcomes were similar between eras.

Incidence and outcome of patients with difficulty in hospital acceptance during COVID-19 pandemic in Osaka Prefecture, Japan: A population-based descriptive study

Aim

The impact of the coronavirus disease (COVID-19) pandemic on the emergency medical service system in Japan has not been fully revealed. The purpose of this study was to determine the impact of the COVID-19 pandemic in 2021 on the difficulty in hospital acceptance of patients and patient outcome in Osaka Prefecture.

Methods

This study was a descriptive epidemiological study with a 3-year study period from January 2019 to December 2021. We included patients who were transported by ambulance and had registered in the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. The primary end-point of this study was the difficulty in hospital acceptance by month, and the secondary outcome was the mortality of patients who experience difficulty in hospital acceptance in each year.

Results

We included 1,302,646 cases in this study. The proportion of cases with difficulty in hospital acceptance was 2.74% (12,829/468,709) in 2019, 3.74% (15,527/414,987) in 2020, and 5.09% (21,311/418,950) in 2021. The crude odds ratio for 2020 was 1.38 (95% confidence interval, 1.35-1.41) and for 2021 was 1.90 (95% confidence interval, 1.86-1.95). In 2019, 218 patients with difficulty in hospital acceptance had died by 21 days after hospitalization, whereas the number increased to 405 in 2020 and 750 in 2021.

Conclusion

The number of patients experiencing difficulty in hospital acceptance during the COVID-19 pandemic in Osaka Prefecture increased, and patient outcomes were worse than before the pandemic.

The impact of COVID-19 pandemic on the urgency of patients admitted to the emergency department

Background

Methods

Results

Conclusion