Emergency Medicine

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

a b s t r a c t

Introduction: The COVID-19 pandemic has been challenging for healthcare systems in the United States and glob- ally. Understanding how the COVID-19 pandemic has impacted emergency departments (EDs) and patient out- comes 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- Feb- ruary 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 pan- demic 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.

(C) 2023

  1. Introduction

The COVID-19 pandemic has been challenging for healthcare systems in the United States and globally, with COVID-19 claiming over one mil- lion lives in the United States since March 2020 [1]. Initial studies that an- alyzed the impact COVID-19 had on the emergency department (ED) during the first several months of the pandemic showed decreased pa- tient volumes and hospital admission [2-10]. However, these studies fo- cused on the initial phases of the pandemic, with only one study using patient data as late as September 2020. Since prior studies only evaluated the initial phase of the COVID-19 pandemic, understanding the long-term impact on ED boarding and patient mortality has yet to be studied.

Studies before the COVID-19 pandemic showed ED boarding and in- creased ED length of stay correlated with increased hospital length of

* Corresponding author at: Cleveland Clinic Akron General Department of Emergency Medicine, 1 Akron General Ave., Akron, OH 44307, USA.

E-mail address: [email protected] (E.L. Simon).

stay and in-hospital mortality [11-13]. Early in the COVID-19 pandemic, research showed patients had longer lengths of stay despite decreased ED volumes [14]. However, this study did not report any overall patient outcomes. Our study aims to bridge the literature gap from the COVID- 19 pandemic’s initial phase with more current data.

The primary objective of this study was to determine if the COVID- 19 pandemic impacted ED boarding compared to the year prior to the COVID-19 pandemic. The secondary objective of this study was to deter- mine if there was a difference in all cause in-hospital mortality pre- pandemic and during the COVID-19 pandemic.

  1. Methods
    1. Study design

This was a retrospective cohort study of all patients who presented to one of 17 EDs (11 hospital-based; 6 freestanding) within a large integrated healthcare system. The study timeframe was March 1,

https://doi.org/10.1016/j.ajem.2023.01.049

0735-6757/(C) 2023

2019-February 29, 2020 (pre-pandemic) vs. March 1, 2020-August 31, 2021 (during the COVID-19 pandemic). This study was approved by the Institutional Review Board.

    1. Setting

The population studied included all patients ages 18 and over who presented to an ED within the healthcare system. Our healthcare system EDs are a mix of academic, community, critical access, and freestanding.

    1. Selection of participants

Participants were eligible if they were seen at one of 17 emergency departments within our healthcare system. Patients were excluded if they had missing data.

    1. Data collection

Study data were abstracted from the electronic medical record (EPIC(R), Verona, WA.) via an automated query performed by one data analyst for the healthcare system. The data analyst was blinded to the study hypothesis. Data collected included patient demographic infor- mation, ED setting (freestanding, community, academic), emergency

severity index score (ESI), COVID-19 test result, ED length of stay (defined as the time of patient arrival in the ED until the patient departed the ED), ED disposition (admitted versus discharged), ED boarding, intensive care unit admission, hospital (LOS), and in- hospital mortality. A patient was determined to be boarding if they remained in the ED for >60 min from when their disposition was changed to admitted.

    1. Statistical analyses

Categorical variables were described using frequencies and percent- ages. P-values were obtained from Pearson chi-squared or Fisher’s exact tests for categorical variables. multiple logistic regression analysis was used to compare boarding and in-hospital mortality pre-pandemic vs. during the pandemic. In addition, a subgroup analysis comparing COVID-19 and non-COVID-19 patients during the COVID-19 pandemic study period was performed to evaluate potential differences between patients with COVID-19 and those without COVID-19.

  1. Results

A total of 1,557,513 patient encounters occurred during the study timeframe. Of those encounters, 1,374,790 had complete data sets and

Table 1

Characteristics of participants pre and During C0VID-19 pandemic, N = 1,374,790.

Variable

Overall

(N = 1,374,790)

COVID

(N = 780,329)

Pre-C0VID

(N = 594,461)

p-value

Age

46.21(24.024)

46.94(23.48)

45.24(24.69)

<0.0001

Gender

Female

773,130(56.24)

434,832(55.72)

338,298(56.91)

<0.0001

Male

601,660(43.76)

345,497(44.28)

256,163(43.09)

Race

Black

462,405(33.63)

263,822(33.81)

198,583(33.41)

<0.0001

White

825,589(60.05)

467,893(59.96)

357,696(60.17)

Other

86,796(6.31)

48,614(6.23)

38,182(6.42)

Ethnicity

Hispanic

56,012(4.07)

31,509(4.04)

24,503(4.12)

0.0136

Not Hispanic

1,318,778(95.93)

748,820(95.96)

569,958(95.88)

Payor

Medicaid

488,179 (35.51)

275,731(35.34)

212,448(35.74)

<0.0001

Medicare

362,346 (26.36)

206,912(26.52)

155,434(26.15)

Private

524,265 (38.13)

297,686(38.15)

226,579(38.12)

ESI Level

High

197,780(14.39)

115,251(14.77)

82,529(13.88)

<0.0001

Mod

837,452(60.91)

477,906(61.24)

359,546(60.48)

low

339,558(24.70)

187,172(23.99)

152,386(25.63)

Mortality

No

1,368,272(99.53)

776,066(99.45)

592,206(99.62)

<0.0001

Yes

6518(0.47)

4263(0.55)

2255(0.38)

ED LOS (mins)

165.0(95.0-257.0)

169.0(96.0-265.0)

160.0(94.0-248.0)

<0.0001

Hospital LOS (Days)

3.95(2.18-6.73)

3.98(2.19-6.85)

3.90(2.17-6.45)

<0.0001

ICU

No

1,314,030(95.58)

745,373(95.52)

568,657(95.66)

<0.0001

Yes

60,760(4.42)

34,956(4.48)

25,804(4.34)

COVID-19 diagnosis No

1,352,851(98.40)

758,395(97.19)

594,456(100.00)

<0.0001

Yes

21,939(1.60)

21,934(2.81)

5(0.00)

Boarded

No

1,062,581(77.29)

590,135(75.63)

472,446(79.47)

<0.0001

yes

312,209(22.710

190,194(24.37)

122,015(20.53)

Admission No

1,123,515(81.72)

631,162(80.88)

492,353(82.82)

<0.0001

Yes

251,275(18.28)

149,167(19.12)

102,108(17.18)

Department group FSED

228,180(16.60)

129,523(16.60)

98,657(16.60)

0.9692

HBED

1,146,610(83.40)

650,806(83.40)

495,804(83.40)

Department Type Academic

775,169(56.38)

437,881(56.11)

337,288(56.74)

<0.0001

Community

599,621(43.62)

342,448(43.89)

257,173(43.26)

Statistics presented as mean (SD), or Median (Q1 – Q3), or n (%).

Fig. 1. Monthly boarding in the emergency department pre and during the COVID pandemic.

were included in our study. Demographic data, ESI score, COVID-19 test results, ED LOS, ED disposition, ED boarding, ICU admission, hospital LOS, and in-patient mortality are reported in Table 1. Boarding increased by 22% during the COVID-19 pandemic, (95% CI 1.22(1.20-1.23)). In- hospital mortality increased by 16% during the COVID-19 pandemic, (95%CI 1.16(1.09-1.23)). More patients were admitted during the pan- demic than before the COVID-19 pandemic (26.02% v 24.97%, p < 0.001). Initial triage ESI score for patients who presented to the ED in- creased in both high acuity (13.95% v 13.18%, p < 0.0001) and moderate Acuity groups (60.98% v 59.95%, p < 0.001) during the COVID-19 pan- demic. We found that patients were 88% more likely to board at a hospital-based ED compared to a freestanding ED (95%CI: 1.88 (1.85-1.97)). In addition, we found that patients seen at a hospital- based ED were 229% more likely to die compared to those seen at a free- standing ED (95%CI 2.29 (1.77-2.94)). Boarding and mortality trends pre and post pandemic are shown in Figs. 1 and 2.

A subgroup analysis compared patients diagnosed with COVID-19 to patients without COVID-19. This subgroup contained 780,329 patient encounters and we controlled for age, ESI, race, sex, insurance, ICU ad- mission, ED boarding, COVID-19 diagnosis and whether patients were seen at a freestanding or hospital-based ED. Demographic data for this subgroup is reported in Table 2. Patients diagnosed with COVID-19

had lower initial ESI triage score for both high acuity (26.86% v 14.42%, p < 0.0001) and moderate acuity (67.19% v 61.07%, p < 0.001). Patients diagnosed with COVID-19 had a longer ED length of stay (95%CI 11.77 (9.41-14.12)) and were more likely to be boarded in the ED (95%CI 1.68 (1.63-1.73)). Patients diagnosed with COVID-19 were more likely to be admitted to the hospital (95%CI 2.81 (2.73-2.91)), more likely to be admitted to the ICU (95%CI 2.29 (2.19-2.39)), and had a longer hospital length of stay (95%CI 2.32 (2.19-2.45)). Patients diagnosed with COVID-19 had a significantly in- creased likelihood of in-hospital mortality compared to non-COVID-19 patients (95%CI 3.30 (3.03-3.59)).

  1. Discussion

This study aimed to quantify the impact the COVID-19 pandemic had on ED boarding and in-hospital mortality. We found an overall 22% in- crease in patients boarding in the EDs within a large integrated healthcare system. Concurrently, in-hospital mortality for patients in- creased by 16% during the COVID-19 pandemic. Prior studies have shown that an increase in ED boarding directly correlates to patient morbidity and mortality [11-13,15]. Based on the previous literature, there is a potential correlation between increased ED boarding and

Fig. 2. Monthly mortality pre and during the COVID-19 pandemic.

Table 2

Demographic and other Characteristics of participants During C0VID-19 pandemic, N = 780,329.

Variable

Overall

COVID-19

N = 21,934

Non-COVID-19

N = 758,395

p-value

Age

46.94(23.48)

56.51(20.15)

46.67(23.51)

<0.0001

Gender

Female

434,832 (55.72)

11,855(54.05)

422,977(55.77)

<0.0001

Male

345,497 (44.28)

10,079(45.95)

335,418(44.23)

Race

Black

263,822 (33.81)

7181(32.74)

256,641(33.84)

<0.0001

White

467,893 (59.96)

13,214(60.24)

454,679(59.95)

Other

48,614 (6.23)

1539(7.02)

47,075(6.21)

Ethnicity

Hispanic

31,509 (4.04)

966(4.40)

30,543(4.03)

<0.0001

Not Hispanic

748,820 (95.96)

20,968(95.60)

727,852(95.97)

Payor

Medicaid

275,731 (35.34)

4717(21.51)

271,014(35.74)

<0.0001

Medicare

206,912 (26.52)

7690(35.06)

199,222(26.27)

Private

297,686 (38.15)

9527(43.43)

288,159(38.00)

ESI Level

High

115,251 (14.77)

5892(26.86)

109,359(14.42)

<0.0001

Mod

477,906 (61.24)

14,737(67.19)

463,169(61.07)

low

187,172 (23.99)

1305(5.95)

185,867(24.51)

Mortality

No

776,066(99.45)

21,104(96.22)

754,962(99.55)

<0.0001

Yes

4263(0.55)

830(3.78)

3433(0.45)

ED LOS(minutes)

169.0(96.0-265.0)

233.0(165.0-321.0)

167.0(94.0-263.0)

<0.0001

Hospital LOS (days)

3.98(2.19-6.85)

5.40(3.37-9.8)

3.90(2.15-6.64)

<0.0001

ICU

No

745,373 (95.52)

18,850(85.94)

726,523(95.80)

<0.0001

Yes

34,956 (4.48)

3084(14.06)

31,872(4.20)

Boarded

No

590,135 (75.63)

11,851(54.03)

578,284(76.25)

<0.0001

yes

190,194 (24.37)

10,083(45.97)

180,111(23.75)

ADMISSION

No

631,162 (80.88)

11,568(52.74)

619,594(81.70)

<0.0001

Yes

149,167 (19.12)

10,366(47.26)

138,801(18.30)

Department Group FSED

129,523 (16.60)

2286(10.42)

127,237(16.78)

<0.0001

HBED

650,806 (83.40)

19,648(89.58)

631,158(83.22)

Department Type Academic

437,881 (56.11)

13,435(61.25)

424,446(55.97)

<0.0001

Community

342,448 (43.89)

8499(38.75)

333,949(44.03)

Statistics presented as mean (SD), or Median (Q1 – Q3), or n (%).

in-hospital mortality. The increase in mortality could have also been secondary to an increase in deaths attributed to COVID-19. However, fu- ture studies evaluating this correlation would be warranted.

We also found an increase in high (ESI level 1 or 2) and moderate (ESI level 3) acuity level patients who presented to the ED. These find- ings are supported by a previous study which showed that early in the pandemic, an increase for high and moderate acuity presentations with a concomitant decrease for low acuity presentations [8].

Our results showed an overall increase in patients admitted to the hospital during the COVID -19 pandemic compared to pre-COVID-19. Early in the COVID-19 pandemic, studies revealed an initial decrease in patient volume and hospital admissions [2,4,7-9]. However, our study time frame included both the initial lockdown and post- Lockdown period of the pandemic in our region. These results highlight a more comprehensive view of the impact that the COVID-19 pandemic had on Hospital admission rates.

Our subgroup analysis of COVID-19 patients vs. non-COVID-19 pa- tients showed that COVID-19 patients were more likely to die in the hospital, have a longer ED and hospital length of stay, and were more likely to be boarded in the ED. In addition, COVID-19 patients were more likely to be admitted to the hospital and the ICU than patients without COVID-19. These results show that COVID-19 patients were more likely to impact key ED and hospital metrics. These results can fur- ther help the medical community understand how and where a pan- demic can impact a healthcare system.

This study has several limitations, including those inherent to all ret- rospective studies. First, this study is limited because, since the study’s

timeframe, additional variants of COVID-19 have occurred. Also, be- cause the study includes the first 18 months of the pandemic, the im- pact of the pandemic post-lockdown may be more significant than we identified. Our healthcare system saw the same decreased volume and admissions trend during that time. Second, this study evaluated patients in a large integrated regional healthcare system which may limit its gen- eralizability. However, this system covers urban and rural areas and in- cludes academic, community, and critical access ED settings. As a result, the system serves a diverse patient population. Finally, we did not in- clude the cause of death, as this was outside the project’s scope. Future studies should be considered evaluating the cause of inpatient death during the pandemic.

  1. Conclusion

During the COVID-19 pandemic, ED boarding and in-patient mortal- ity increased. The COVID-19 pandemic also increased moderate, and high acuity patient encounters with an increased percentage of patients admitted to the hospital. In addition, COVID-19-positive patients were more likely to be boarded and admitted, had longer ED and hospital LOS, and had an increased likelihood of ICU admission and in-hospital mortality.

Prior presentations

Society for Academic Emergency Medicine 2022; Cleveland Clinic Akron General Post Graduate Research Day 2022.

CRediT authorship contribution statement

Gregory Griffin: Writing – original draft, Methodology, Investiga- tion, Conceptualization. Jessica Krizo: Writing – review & editing, Project administration, Methodology. Caroline Mangira: Writing – original draft, Software, Methodology, Formal analysis, Data curation. Erin L. Simon: Writing – review & editing, Supervision, Project admin- istration, Methodology, Investigation, Data curation, Conceptualization.

Declaration of Competing Interest

The authors have no conflicts of interest.

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