Emergency Medicine

The burden of the pandemic on the non-SARS-CoV-2 emergencies: A multicenter study

a b s t r a c t

Background: Governments have implemented social distancing interventions to curb the speed of SARS-CoV-2 spread and avoid hospital overload. SARS-CoV-2 social distancing interventions have modified several aspects of society, leading to a change in the emergency medical visit profile.

Objective: To analyze the impact of COVID-19 and the resulting changes on the non-SARS-CoV-2 emergency med- ical care system profile.

Methods: This is a retrospective multicenter cross-sectional study evaluating Medical consultations, urgent hos-

pitalizations, and deaths in Sao Paulo, the largest city of the Americas. Changes in the medical visit profile accord- ing to demographic data and diagnoses were assessed. The change in mortality was also assessed.

Results: A total of 462,412 emergency medical visits were registered from January 2019 to July 2020. Of these emergency medical visits, only 4.7% (21,653) required hospitalization. Of all visits, 592 resulted in deaths, equiv- alent to 0.1% of the sample. There was a clear decreasing trend in the number of weekly emergency medical visits as social distancing was mandated by decree (Coef. -3733.13; 95% CI -4579.85 to -2886.42; p < 0.001). The number of medical visits for conditions such as trauma, abdominal pain, chest pain, and the common cold de- creased (p<0.05). However, the number of medical visits for the following conditions did not change after the onset of the pandemic (p>=0.05): ureterolithiasis, acute appendicitis, acute cholecystitis, acute myocardial infarc- tion, and stroke.

Conclusion: The COVID-19 pandemic has changed the non-SARS-CoV-2 emergency profile. The overall number of emergency medical visits has reduced. The mortality of non-SARS-CoV-2 emergencies has not increased in Sao Paulo.

(C) 2021

  1. Introduction

The WHO first reported coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, on December 31, 2019, after Chinese authori- ties reported a series of mysterious pneumonia cases in Wuhan [1]. Since then, over 66 millions of new cases have been reported, with over 1.5 million deaths [2] The current generation of health-care profes- sionals has never seen such a devastating spread of an infectious disease as it has with COVID-19.

Governments have implemented social distancing interventions to reduce the speed of SARS-CoV-2 spread and avoid hospital overload, and home confinement measures have been ordered in most countries [3,4]. Patients were advised by the authorities to stay home unless they had a severe condition.

* Corresponding author.

E-mail address: [email protected] (F. Tustumi).

Consequently, SARS-CoV-2 social distancing interventions have changed several aspects of society, including social and entertainment activities, traffic, and job routines, and even psychosocial patterns, which may have changed the demand profiles for all medical emergen- cies [5-7]. While previous studies dealt with specific disease or condi- tion during a pandemic period, literature lacks of an overview of all medical conditions burden on the emergency department. Several dis- eases that were highly incident before the pandemic are still common, and currently, the whole emergency care system must shoulder both SARS-CoV-2 and non-SARS-CoV-2 emergencies.

Social distancing measures were enacted on March 22, 2020, in the state of Sao Paulo, Brazil. From this moment on, face-to-face services in commercial establishments, nightclubs, shopping centers, schools, and gyms were no longer allowed. Only essential services, such as health, food, drug, security, and supply services, were permitted (De- cree N? 64.881; State of Sao Paulo, March 22, 2020).

Knowing the changes in emergency health-care system patterns al- lows authorities to direct health-resource allocation. This study aims to

https://doi.org/10.1016/j.ajem.2020.12.080

0735-6757/(C) 2021

analyze the impact of the COVID-19 and the resulting changes on the non-SARS-CoV-2 emergency profile.

  1. Methods

This is a retrospective multicenter cross-sectional study evaluating medical consultations, urgent hospitalizations, and deaths in Sao Paulo, of all non-SARS-CoV-2 emergencies (all COVID-19-related condi- tions were excluded). Data were extracted from the records of all emer- gency hospitalizations and deaths at emergency care hospitals of the Albert Einstein System, all of them located in Sao Paulo. Sao Paulo is the largest city of the Americas, comprising more than 21 million inhab- itants and was where the first COVID-19 case was diagnosed in South America. It is the leading city in Brazil in number of COVID-19 cases, with almost 0.5 million cases [8].

The Albert Einstein System is a non-profit health society that has established several partnerships with the Sao Paulo Health Department, implementing healthcare services. The present study included nine emergency care units (Unidade de Pronto Atendimento) managed by the Albert Einstein System in Sao Paulo.

All patients of the emergency care units were included. All patients were evaluated by physicians. In this observational study, the exposi- tion was the social distancing period, and the outcome variable was the number of medical visits. Thus, the change in the number and profile of emergency visits across months in the 2019-2020 period according to sex, age, specialty, and diagnosis were assessed, and a comparison was made before and after the social distancing decree (March 22, 2020). The Albert Einstein Ethics Committee approved this study (CAAE: 32353120.2.0000.0071). STROBE statement was followed for reporting [9].

    1. Statistical analysis

Continuous variables were described by means and standard devia- tions or medians and interquartile ranges. Categorical variables were shown as relative and absolute frequencies. Comparisons between con- tinuous variables were performed using the Mann-Whitney test.

All hospitals included in this study use a common medical chart sys- tem in which all clinical data are prospectively inserted. An epidemiol- ogist abstracted the variables of interest. The data were transferred to a computed database for subsequent statistical analysis. The epidemiol- ogist was blinded to the study hypothesis. All medical visits of the emer- gency care units with non-SARS-CoV-2 related conditions were included.

The number of emergency care visits over time and its relationship with the onset of social distancing in the state of Sao Paulo were assessed by Time series regression models, with autoregressive inte- grated moving average. The number of visits in the period was the re- sponse variable and the beginning of the pandemic was the explanatory variable. The R (R Core Team, 2015) and forecast (Hyndman et al., 2008) packages and the statistical software Statistical Package for the Social Sciences – SPSS, v26.0, (IBM Corp, 2019) were used. The level of significance adopted was 0.05.

  1. Results

A total of 462,412 emergency medical visits were registered from January 2019 to July 2020. All medical visits of the emergency care units with non-SARS-CoV-2 related conditions were included, and charts for 4248 (<1%) visits were missing information concerning the outcome “death or discharge”. These were excluded only from analysis of this outcome. No other exclusion criteria were adopted. No other ex- clusion criteria were adopted. 4.7% (21,653) of patients were hospital- ized. Of all visits, 592 resulted in deaths, equivalent to 0.1% of the sample (see Fig. 1). In the casuistry, there was a slight female predomi- nance (58%). The majority of the patients were children and adolescents (<16 years-old), or adults (<45 years-old). The main emergency de- partment consultations were directed to general practitioners (52%); pediatrics (27%); and surgeons (25%). The baseline characteristics of the patients are shown in Table 1. (See Table 2.)

A clearly decreasing trend was observed in the number of weekly emergency medical visits as social distancing was mandated by decree (Coef. -3733.13; 95% CI -4579.85 to -2886.42; p<0.001). The number

of medical visits decreased for all age groups, sexes, and specialties. The number of medical visits for several conditions have dropped, such as traumatic brain injury (Coef. -16.21; 95% CI -22.82 to -9.61;

p<0.001); polytrauma (Coef. -0.88; 95% CI -1.71 to -0.05; p=0.039);

scalp and facial injury (Coef. -22.54; 95% CI -28.75 to -16.33;

p<0.001); abdominal pain (Coef. -93.05; 95% CI -115.29 to -70.81;

p<0.001); Acute diverticulitis (Coef. -6.55; 95% CI -9.08 to -4.02;

p<0.001); chest pain (Coef. -43.23; 95% CI -59.01 to -27.45;

p<0.001). An intense reduction in the common cold visits, non-related to SARS-CoV-2 infection, was also observed (Coef. -121.87; 95% CI

-170.99 to -72.75; p<0.001). However, the number of visits for the fol- lowing conditions did not change after pandemic onset: ureterolithiasis (Coef. -12.91; 95% CI -27.75 to 1.93; p=0.088); acute appendicitis (Coef.

-1.57; 95% CI -3.39 to 0.26; p=0.092); acute cholecystitis (Coef. -1.32; 95% CI -2.74 to 0.10; p=0.067); acute myocardial infarction (Coef.

Fig. 1. Flow diagram of all the emergency medical visits registered from January 2019 to July 2020.

Table 1

Baseline characteristics of the patients in the period from January 2019 to July 2020

Table 2

The change in the number of emergency medical visits after pandemic onset

Baseline characteristics

Before pandemic

%

Pandemic period

%

Coef.

95% CI

p-value

All

427,976

100

34,436

100

Lower

Upper

Overall number of emergency medical visits

Sex

Female

229,323

53.6

18,208

52.9

Male

198,629

46.4

16,223

47.1

Age

< 16 years

138,819

32.4

4965

14.4

-3733.13 -4579.85 -2886.42 <0.001

Sex

Female -2126.85 -2445.21 -1808.49 <0.001

Male -1718.83 -2119.49 -1318.16 <0.001

16 to 29 years

54,580

12.8

3978

11.6

30 to 44 years

124,647

29.1

12,500

36.3

Specialties

45 to 59 years

66,213

15.5

7848

22.8

General practitioner

-1696.73

-1951.95

-1441.52

<0.001

60 to 74 years

27,698

6.5

3179

9.2

Surgery

-861.96

-1080.81

-643.11

<0.001

>74 years

16,019

3.7

1966

5.7

Pediatrics

-1260.55

-1564.85

-956.24

<0.001

Gynecology

-52.27

-79.68

-24.87

<0.001

Diagnosis

Traumatic brain injury

2480

0.6

336

1

Age

Polytrauma

111

<0.1

13

<0.1

< 16 years

-1521.84

-1890.09

-1153.60

<0.001

Scalp and facial injury

3663

0.9

553

1.6

16 to 29 years

-525.68

-576.35

-475.01

<0.001

Abdominal pain

10,259

2.4

907

2.6

30 to 44 years

-1051.18

-1191.96

-910.40

<0.001

Ureterolithiasis

3230

0.8

691

2

45 to 59 years

-494.80

-613.81

-375.80

<0.001

Acute appendicitis

706

0.2

160

0.5

60 to 74 years

-198.93

-247.70

-150.17

<0.001

Acute diverticulitis

947

0.2

130

0.4

>75 years

-120.66

-148.04

-93.28

<0.001

Acute cholelithiasis

287

0.1

54

0.2

Chest pain

Acute myocardial infarction

6748

189

1.6

<0.1

964

56

2.8

0.2

Diagnostic

Traumatic brain injury

-16.21

-22.82

-9.61

<0.001

Stroke Common cold

135

11,802

<0.1

2.8

20

521

0.1

1.5

Polytrauma

Scalp and facial injury

-0.88

-22.54

-1.71

-28.75

-0.05

-16.33

0.039

<0.001

Abdominal pain

-93.05

-115.29

-70.81

<0.001

Specialty

Ureterolithiasis

-12.91

-27.75

1.93

0.088

General practitioner

203,561

47.6

20,410

59.3

Acute appendicitis

-1.57

-3.39

0.26

0.092

Surgery

97,867

22.9

8922

25.9

Acute diverticulitis

-6.55

-9.08

-4.02

<0.001

Pediatrics

112,887

26.4

3430

10

Acute cholelithiasis

-1.32

-2.74

0.10

0.067

Gynecology

9567

2.2

1295

3.8

Chest pain

-43.23

-59.01

-27.45

<0.001

Others

4094

1

379

1.1

Acute myocardial infarction

-0.53

-1.49

0.43

0.282

Stroke

-0.65

-1.41

0.12

0.098

Common cold

-121.87

-170.99

-72.75

<0.001

-0.53; 95% CI -1.49 to 0.43; p=0.282); and stroke (Coef. -0.65; 95% CI

Outcome

Discharge after initial evaluation -3744.44 -4551.98 -2936.90 <0.001

-1.41 to 0.12; p<0.001). A significant reduction in hospital admissions was identified (Coef. -68.51; 95% CI -102.33 to -34.69; p<0.001). No significant increase in the number of deaths associated with non-

Hospital admission after initial evaluation

Death or discharge

-68.51 -102.33 -34.69 <0.001

SARS-CoV-2 emergencies was observed after the pandemic onset and social distancing decree in Sao Paulo (Coef. 0.22; 95% CI -1.3 to -1.74; p=0.777). The mean numbers of monthly emergency medical visits and deaths are illustrated in Figs. 2 and 3.

  1. Discussion

These multicenter study results show that the number of emergency visits for most non-SARS-CoV-2-related conditions was greatly reduced. However, this was not the case for some nontraumatic surgical emer- gencies and Cardiovascular emergencies. Fortunately, the mortality of non-SARS-CoV-2 emergencies has not significantly increased after pan- demic onset and the social distancing decree in Sao Paulo.

One of the biggest fears of the SARS-CoV-2 pandemic was that COVID-19 would rapidly increase mortality due to non-SARS-CoV-2 emergencies with the collapse of health services due to COVID-19 [10]. The dramatic change in the emergency medical visit profile proba- bly helped in some way to avoid an expressive increase in the mortality of non-SARS-CoV-2 emergencies.

The intense reduction in traffic probably changed the trauma emer- gency service profile, explaining the large reduction in traumatic inju- ries. Land-based transport accidents are quite relevant in Sao Paulo due to heavy traffic and many motorcycles [11,12]. Many trauma- related injuries are caused by car crashes, Motorbike accidents, acci- dents involving pedestrians, or bicycle accidents [12]. Consequently, the reduced traffic density may have affected the number of these accidents.

Hospital discharge -3787.86 -4614.01 -2961.71 <0.001

Death 0.22 -1.30 1.74 0.777

Additionally, it is well known that several types of interpersonal vi- olence occur in streets. The end of parties, the closure of pubs and bars, and the comprehensive ban of large gatherings may have helped reduce these causes of trauma [13]. On the other hand, restrictive mea- sures may have changed the victim profile. The home confinement or- ders left many victims trapped with their aggressors. domestic violence increased during the pandemics [14]. Restrictive measures may also have adversely impacted mental health, which would favor in- terpersonal violence and self-harm behavior [15].

The number of emergency medical visits due to abdominal pain, chest pain, and the common cold has also meaningfully reduced after the onset of the pandemic. Patients with mild symptoms probably did not seek medical care, which would have happened before home con- finement measures. On March 23rd, people were vaccinated against the most common influenza strains (subtype A/H1N1 and H3N2; and subtype B/Victoria) throughout Sao Paulo city [16]. Flu vaccination can affect the number of fever patients visiting the emergency room, and avoid overburdening health services [17]. Additionally, mask wearing, Hand hygiene, and social distancing during the COVID-19 pandemic may have helped to reduce transmission of the common cold [18].

Some medical conditions did not change after home confinement or- ders. These conditions include non-SARS-CoV-2-related acute myocar- dial infarction and stroke. It is essential for health-care providers to

Image of Fig. 2

Fig. 2. The change in the mean number of emergency medical visits (EMV) in 2019 and 2020. A: The overall number of emergency medical visits; B: The number of hospital admissions; C: The number of deaths.

allocate resources for these conditions. Cardiovascular intensive care re- sources are already burdened by COVID-19-related cardiovascular com- plications [19]. Additionally, ureterolithiasis, acute cholelithiasis, and acute appendicitis are conditions that have not been reduced after pan- demic onset. Several of these conditions demand surgical intervention,

and hospitals have to cope with and address emergency surgeries. Care should be taken to avoid transmission for patients and medical staff during these surgeries [20,21].

Giamelllo et al. [22], in an Italian two-center study that comprises over 45,000 emergency department examinations annually, showed a

Image of Fig. 3

Fig. 3. The change in the mean number of emergency medical visits (EMV) in 2019 and 2020 according to the diagnosis. A: Traumatic brain injury; B: Polytrauma; C: Scalp and facial injury; D: Abdominal pain; E: Ureterolithiasis; F: Acute appendicitis; G: Acute diverticulitis; H: Acute cholelithiasis; I: Chest pain; J: Acute myocardial infarction; K: Stroke; L: Common cold.

significant drop in the emergency visits for anxiety, back and joint pain, abdominal pain, general malaise, dizziness in 2020 compared to 2019. Unlike our findings, they observed a reduction in acute coronary syn- drome cases. De Filippo et al., [23], in a study comprising 15 hospitals in Italy focused on coronary admissions, also showed a significant re- duction on acute coronary syndrome on the pandemic period. However, as noted by Vecchio et al. [24], the number of intensive care admissions for non-primarily Cardiac conditions has raised. Probably the reduction on non-SARS-CoV-2 coronary syndrome is due to the fact that several cases of acute myocardial infarction have been diagnosed as COVID-19 related complications [19]. Thus, policymakers should keep special at- tention on coronary syndrome in the pandemic period, both for SARS- CoV-2 and non-SARS-CoV-2 related conditions.

This study has some limitations. The retrospective nature and large sample size of this multicenter work resulted in high heterogeneity among patients, diseases, hospitals, and emergency management proto- cols. Although the external validity of the present findings is undeter- minable, Sao Paulo showcases all the significant challenges inherent in several worldwide metropolises concerning society’s complexity and density, health system network, traffic, and violence, among others. Fu- ture population-based studies will be necessary to determine the valid- ity of the findings of the present study in other major metropolises with longer follow-up. Also, future studies also should focus on the specific mortality, according to each disease category.

  1. Conclusion

The COVID-19 pandemic has changed the non-SARS-CoV-2 emer- gency profile. The overall number of emergency medical visits has re- duced, and the mortality of non-SARS-CoV-2 emergencies has not increased.

The study was not funded.

Author contributions

Wolosker was responsible for the study conception and design, manuscript preparation and critical revisions. Steinman was responsible for the acquisition of data, statistical analyses, Data interpretation, and critical revisions. Tustumi was responsible for the data acquisition and interpretation, and statistical analyses. De Souza was responsible for the statistical analyses, data interpretation and critical revisions and was responsible for the study conception and design, and critical revi- sions. All of the authors approved the final version of the manuscript.

Ethics

The local ethics committee approved the study.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

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