Emergency Medicine

Decline in emergency department visits during the COVID-19 quarantine

a b s t r a c t

Background: Emergency department (ED) visits can be divided into urgent and non-urgent. A delay in seeking medical help, especially in urgent cases, can lead to fatal consequences, along with a higher rate of complications and morbidity. Coronavirus disease 2019 (COVID-19) pandemic spread led to restrictions and eventually quaran- tines. We investigated the impact of the COVID-19 spread and quarantine on ED visits rates comparing to parallel periods in preceding years (2013-2019). In addition, we compared this decrease to holidays and weekends, times in which a decrease in ED visits is seen.

Methods: This was a descriptive retrospective study. Causes of ED referrals were divided into urgent and non- urgent, then into different subcategories including infectious, cardiac, etc.

Results: For the spring COVID-192020 quarantine period, a 56.3% decrease of mean ED visits per day was seen, as compared to preceding years (55.7% and 98.9% respectively). This decrease was also statistically evident when comparing the urgent and non-urgent causes separately and for all sub-categories. This pattern of decrease also showed statistical evidence of fewer ED visits during holidays for most comparisons, in which lower ED visit rates are expected. Significantly lower rates of ED visits were demonstrated during the COVID-19 quarantine period, as compared to preceding years and main holidays and weekends, a decrease that was also demonstrated for urgent life-threatening causes.

Conclusion: Our findings can be used to inform a wide range of stakeholders, including regional planners, histo- rians, sociologists, and international Healthcare organizations. Healthcare providers should understand the rea- sons for this ED visit decline pattern, attempt to address patients’ concerns, and increase awareness regarding alarming symptoms in urgent medical situations.

(C) 2023

  1. Introduction
    1. Background and importance

The Coronavirus disease 2019 (COVID-19) outbreak, with its alarming spread, was rapidly defined as a worldwide pandemic by the World Health Organization (WHO) [1]. A quarantine was applied in many countries around the globe, in which schools were closed, people were ordered to stay home, family visits were banned, and shopping was prohibited. As a result, this major global crisis caused social isola- tion, unemployment, and major economic disruption [2]. Data concern- ing the disease’s spread, morbidity, and mortality disseminated quickly, leading to worrisome aggravated panic and distress [3]. Prolonged

Abbreviations: ED, Emergency department; STEMI, ST-elevation myocardial infarction.

* Corresponding author at: Department of Otolaryngology Head and Neck Surgery, Galilee Medical Centre, affiliated with Azrieli Faculty of Medicine, Bar Ilan University, POB 21, Nahariya 210001, Israel.

E-mail address: [email protected] (O. Ronen).

quarantine, fear of infection, frustration, and misinformation caused COVID-19 to not only present a physical health issue, but also create a major psychological negative impact [4,5].

In Israel, the first diagnosed patient with COVID-19 was documented on February 22nd, 2020. In order to preclude the spread of the virus in Israel, schools and child-care facilities were closed on March 12th, 2020. Further on, gradual restrictions were applied by the government, leading to the decision on declaring a quarantine period throughout the country.

Changes in medical priorities were implemented among all healthcare systems. Many of its human and technical resources were re-arranged and dedicated to the COVID-19, and as a consequence, neglected all non-COVID-19 conditions. In addition, in the COVID-19 pe- riod, several reports published in the local journals and the global press claimed that there is a decline in the non-COVID-19 virus patients’ visits to emergency departments (ED) [6,7]. Patients seemed to postpone medical treatments in the ED to avoid the possibility of being infected with the COVID-19 virus [8,9]. Overseas, studies showed a substantially reduced rate of hospital admissions for acute coronary syndrome during

https://doi.org/10.1016/j.ajem.2023.06.002

0735-6757/(C) 2023

the Covid-19 outbreak period [10,11]. Moreover, the number of dying children from non-coronavirus illnesses was escalating, possibly as parents misleadingly were warned to avoid hospitals visits during the pandemic [12].

Israel, a multi-ethnic country, is populated by Jews, Muslims, Christians and Druze who celebrate diverse holidays on different dates. Religious Jews, on holidays and on Saturdays, observe religious laws that entail refraining from work, and engaging in restful honoring of these days. Weekends, mainly Saturdays, are non-work days for most of the country and are considered resting days.

Scarce inconsistent literature addresses the ED visits rates during holidays. While some studies suggest an increase in ED visits during hol- idays [13,14], others present the opposite [15,16]. A decrease in the di- agnosis of acute coronary syndrome was demonstrated in one study [17], while others pointed to an increase in visits due to renal stones and acute pancreatitis [18,19].

    1. Goals of this investigation

In this study, we present data on the rate of admissions to ED in our mid-size medical centre, during the COVID-19 spread period, as com- pared to parallel periods prior to the outbreak. In addition, we compared this change to those seen on holidays in recent years, as another control period.

  1. Methods
    1. Study design and setting

This is a single institute descriptive retrospective study. This institute is an Urban academic medical center which includes a trauma unit.

    1. Ethical approval

Prior study initiation approval of the institutional review board (Helsinki Committee) was granted.

    1. Selection of participants and outcomes measures

Data were collected from patients’ ED electronic medical files using a predetermined list of commonly used ICD-9 codes [20]. Dates chosen for data retrieval were between the years 2013-2020 for major Jewish hol- idays and Saturdays (in which religious observance is practiced), Coronavirus quarantine period in Israel (12/3/2021-17/4/2021), and weekdays. The control dates for each category were non-holiday week- days chosen from parallel dates of prior years. The data extracted

included demographics of age, sex, and ethnicity, date of admission, and the ICD-9 codes used for each patient. Trauma patients were ex- cluded due to foretold lower rates of ED visits during the coronavirus period because of less road traffic and congestion, and less work- related trauma. For patients with more than one ICD-9 code, the more urgent complaint was chosen, using a predetermined list. In patients where two ICD-9 codes were assigned and both were regarded as ur- gent, the patient’s electronic data file was reviewed fully, and a code was determined accordingly. The Review process was performed by a physician who works at our medical center and who is experienced with performing data extraction and analysis. Prior to data extraction, many ED doctors were approached and asked which ICD-9 codes they use the most. Moreover, several days of ED activity were surveyed and analysed. Accordingly, a list of the most utilized ICD-9 codes was obtained.

A comparison of ED visit rates was performed between the different periods listed above. Furthermore, additional comparisons in the sub- categories of urgent, non-urgent, cardiac, neurologic, respiratory, infec- tious, gastrointestinal, and otolaryngologic diagnoses were completed. For the comparisons between the coronavirus quarantine period and the category of holidays, which included Jewish holidays and Saturdays, and to make the comparison representative, patients of any other reli- gion than Jewish were removed from the quarantine period category.

    1. Primary data analysis

Data analysis was performed using IBM SPSS (version 27.0). Categorical data were described using frequencies and percentages. Continuous variables with normal distribution were presented as mean +- standard deviation. Median value and range were used for variables that did not meet the normal distribution assumption. Contin- uous variables’ comparisons were performed using independent t-test or Wilcoxon rank-sum test depending on variables’ distribution. If a normal distribution was found using a histogram, independent t-test was conducted. Statistical significance was defined as p < 0.05.

  1. Results
    1. Characteristics of study subjects

Overall, 290,862 records were obtained using 69 commonly used ICD-9 codes, (Table 1). For patients with more than one assigned ICD- 9 code, the more urgent and plausible cause for an ED visit was chosen. In 682 patients, due to difficulty in deciding which ICD-9 code was more representative for the cause of visit, patients’ electronic data files were reviewed, and the more appropriate code was chosen accordingly.

Table 1

Diagnoses list used in this study subdivided into urgent and non-urgent groups.

Urgent

Non-Urgent

Atrial fibrillation

Acute appendicitis

Myocardial infarction

Ascites

atrial flutter

Anaphylaxis

Mastoiditis

Cough

Ventricular tachycardia

Dyspnea

Supraglottitis, Epiglottitis

Foreign body in ear

Superior ventricular tachycardia

Blood in stool

Pulmonary embolism

Impacted cerumen

Sinoatrial node

Hematemesis

Vascular insufficiency of intestine

Acute otitis externa

Pneumonia

Renal colic

Thrombophlebitis

Acute sinusitis

Other dysrhythmias

gastrointestinal hemorrhage

Venous embolism & thrombosis

Acute tonsillitis

Ventricular fibrillation

subperiosteal abscess

CVA

Perichondritis

Cardiac arrest

Suicide

Convulsions

Acute bronchitis

Hypotension

Poisoning

Epilepsy

Otitis media

Sepsis, Septic shock, Severe sepsis

Asthma

Epistaxis

Headache

Shock

COPD exacerbation

Post tonsillectomy bleeding

Fever

Cardiogenic shock

Cardiac tamponade

Abdominal pain

Dizziness, Vertigo

Perforation of intestine

Pericarditis

Chest pain

Backache

Peritonitis

Myocarditis

Syncope

Cellulitis

Heart failure Acute, subacute endocarditis Bell’s palsy Tachycardia Premature beats

Foreign body in pharynx Foreign body in larynx Foreign body in esophagus Foreign body in trachea

Image of Fig. 1

Fig. 1. Flowchart of Selection process.

The selection process of medical records included in the study.

After exclusion of duplicates and irrelevant cases, 118,053 patients were included in the study (Fig. 1); the mean age of patients was 47.8 (std. 25.4) of which 49% were male, (Table 2).

    1. Overall comparisons

For the spring COVID-19 quarantine period, mean ED visits per day were 55.7, while on parallel dates in preceding years between 2013 and 2019 the mean ED visits per day were 98.9, presenting a 77.5%

higher rate of visits, which showed statistical evidence for a difference (p < 0.001), (Fig. 2). The mean age of patients visiting the ED during the COVID-19 quarantine was 48 compared to 48.45 in the control group (p = 0.379) and statistical evidence for a difference in male pre- dominance was noted during the COVID-19 period (51.4% vs. 49.4%, p = 0.045), (Table 2). Furthermore, overall visits per week during the COVID-19 period were calculated and compared to preceding years, exhibiting a lower rate of visits during the COVID-19 period, (Fig. 3). Moreover, when comparing the coronavirus quarantine period to the holidays (which included official religious Jewish holidays and Satur- days – the national day off work, religiously mandated for practicing Jews), statistical evidence for a lower rate of ED visits was observed throughout the coronavirus quarantine period (p < 0.001). Concerning holidays, the average ED visit rate during major holidays was 34 visits per day, as compared to 43.6 visits per day on weekdays, demonstrating a 22% decrease during holidays, which showed a statistical evidence dif- ference (p < 0.001), (Fig. 4).

    1. Urgent and non-urgent causes

ICD-9 codes were subdivided into urgent and non-urgent codes for patient visits, (Table 1). For urgent complaints, patients seemed to seek medical help significantly less during the COVID-19 quarantine pe- riod (40.5 visits per day), showing a 47.5% decrease when compared to their control group (69.8 visits per day, p < 0.001). While significantly lower rates of ED visits were seen during holidays as compared to week- days for urgent causes (23.3 vs. 30.2 visits per day respectively, p < 0.001), an even lower rate, with a 15% decrease, was seen during the quarantine period (19.8 visits per day) when compared to holidays, p < 0.001, (Figs. 2 and 4).

For non-urgent complaints, the same comparisons as above were performed. During the quarantine, a 42% decrease was seen when com- pared to the control group (40.5 vs. 69.8, p < 0.001). Moreover, for Jews, a 29.7% decrease in the rates of visits per day during the COVID-19

Table 2

Patient characteristics.

Overall Corona Control-Corona p-value

Total number of patients 118,053 2061

19,479 –

(Children, %)

(234, 12.8%)

(2577, 15.2%)

Mean age in years +- standard deviation

47.78 +- 25.44

47.96 +- 24.21

48.45 +- 25.81

0.379

Male (%)

49%

51.4%

49.4%

0.045

Image of Fig. 2

Fig. 2. COVID-19 quarantine period compared to its control group.

Percentage of change in average ED visits per day during the COVID-19 quarantine period when compared to it control group.

* All comparisons showed statistical evidence of difference.

Image of Fig. 3

infectious causes“>Fig. 3. Overall ED visits per week.

Average ED visits per week during the COVID-19 quarantine period compared to similar periods in preceding years.

quarantine period was seen when compared to their holidays (7.5 vs. 10.7, p < 0.001). Lastly, on holidays, a lower rate of visits was demon- strated when compared to weekdays, p < 0.001. (Figs. 2 and 4).

    1. Cardiac

For cardiac causes, significantly lower rates were demonstrated dur- ing the COVID-19 period, as compared to their control group (13.2 vs. 23.2, a 48.5% decrease, p < 0.001). Comparing Jewish holidays, while no statistical evidence for a difference was demonstrated when com- pared to weekdays (p = 0.95), a 39.3% decrease was seen during the quarantine period when compared to holidays (1.5 vs. 2.4, p < 0.001). (Figs. 2 and 4).

    1. Infectious causes

ICD-9 infection codes were compared separately. During quarantine, mean average visits per day was 10.8, compared to 17.8 in the control

group (p < 0.001). Moreover, significantly lower visit rates per day were demonstrated when comparing the quarantine period to previ- ously mentioned holidays. (5.4 vs. 7.5, p < 0.001). On weekdays, statis- tical evidence for higher rates of ED visits were seen (8.1 visits per day), as compared to holidays (p = 0.004), (Figs. 2 and 4).

    1. Gastrointestinal

For gastrointestinal causes, all comparisons previously listed showed statistical evidence for a difference, demonstrating the lowest rates dur- ing the quarantine period, followed by holidays, and lastly, control groups, p < 0.001 for all comparisons (Table 3).

    1. Otolaryngologic diagnoses

Statistical evidence for lower rates of ED visits were seen during the COVID-19 quarantine period (3.7 visits per day) when compared to the control group (6.03, p < 0.001). While similar rates of ED visits were

Image of Fig. 4

Fig. 4. Holidays compared to the quarantine period and to non-Holiday prior COVID-19 group.

Percentage of change in average ED visits per day during the COVID-19 quarantine period and holidays when compared to weekdays.

+ Statistical evidence of difference comparing mean visits per day during Holidays and quarantine period.

* Statistical evidence of difference comparing mean visits per day during Holidays and non-Holidays.

Table 3

Average ED visits per day for the different periods and categories defined.

Category COVID-19

COVID-19

Patients belonging to Jewish

Holidays Weekdays p value

quarantine period

control

Religion during quarantine

Quarantine period vs.

Control group

Holidays vs. Weekdays

Holidays vs. Quarantine period

Overall

55.7

98.88

27.38

34.02

43.58

<0.001

<0.001

<0.001

Urgent

40.46

69.84

19.86

23.33

30.21

<0.001

<0.001

<0.001

Non-Urgent

15.24

29.04

7.51

10.69

13.38

<0.001

<0.001

<0.001

Cardiac

13.22

23.17

1.46

2.40

2.40

<0.001

0.947

<0.001

Infectious

10.78

17.82

5.41

7.49

8.09

<0.001

0.004

<0.001

Gastrointestinal

12.3

23.9

5.49

8.04

10.47

<0.001

<0.001

<0.001

ENT

3.73

6.03

1.00

1.71

1.57

<0.001

0.09

0.022

Neurologic

5.35

8.63

2.62

2.80

3.99

<0.001

<0.001

0.552

Respiratory

10.46

15.69

5.65

5.55

5.76

<0.001

0.274

0.797

seen during holidays and weekdays, statistical evidence for lower ED rates were seen during the quarantine when compared to holidays (p = 0.022), (Table 3).

    1. Neurologic

Neurologic causes, including stroke, showed a 33.3% decrease in ED visits during the quarantine period as compared to the control group (5.4 vs. 8.6, p < 0.001). On holidays, compared to weekdays, a statistical evidence decrease was seen (p < 0.001). Surprisingly, a minor non- significant decrease was seen during the quarantine period when com- pared to holidays (2.6 vs. 2.8, p = 0.55), (Table 3).

    1. Respiratory

A 38% decrease in ED visits was seen during the quarantine period, as compared to the control group. Holidays demonstrated statistical evi- dence of lower rates of ED visits when compared to weekdays. However, no statistical difference was seen between the coronavirus period as compared to the holidays, (Table 3).

  1. Discussion

During the spring COVID-19 quarantine period, mean ED visit rates demonstrated a statistically evidenced decrease when compared to similar dates in previous years (2013-2019; 55.7 vs. 98.9 average visits per day, p < 0.001) and declined in each subcategory, including the ur- gent, non-urgent cardiac, infectious, neurologic, and respiratory subcat- egories (p < 0.001 for all these comparisons). This finding is consistent with recent studies reporting a similar pattern, especially at the begin- ning of the pandemic, where fear and uncertainty were ruling [8,21- 23]. Wong et al. reported a 50% decrease in ED visits in the USA during the COVID-19 quarantine when compared to the previous year, and in- terviews with patients revealed a dominant theme of fear of the pan- demic, rather than from their non-COVID-19 health issues [24]. A similar study showed a significant decrease in ED visits overall for many complaints, including a 58.3% decrease in ED visits due to cerebro- vascular incidents [25].

In the current study, no statistical evidence for a difference in age was seen between the two groups (48 vs. 48.45, p = 0.379). However, the percentage of men compared to women showed a statistically sig- nificant increase during the pandemic (51.4% vs. 49.4% respectively, p = 0.045). A similar finding was seen in a study on ED visits during the pandemic, with a greater decrease in ED visits for women [23]. This might be explained that with schools and daycare centres closed, women, much more so than men, spent additional time caring for children [26].

While some studies have demonstrated a more prominent decrease in ED visits in the Paediatric population compared to adults [12,23], our findings found the opposite, showing a 48% decrease in children’s visits

compared to a 57% decrease in the adults group, though this finding was not statistically significant.

Holidays showed an overall significant decrease in ED visits com- pared to weekdays, however, even lower rates of ED visits were demon- strated during the COVID-19 quarantine period (p < 0.001). This finding was also demonstrated in the urgent, non-urgent, cardiac, infectious, and gastrointestinal subcategories (p < 001 for all comparisons). Pa- tients who already exhibit lower rates of ED visits during holidays and weekends, for many potential reasons, including observing the Sabbath, and other related practices, had much lower rates of ED attendance dur- ing the quarantine period. Many factors are believed to contribute to this phenomenon, including the fear of “catching the virus”, and the strict instructions of staying home, both of which led the patient to try and overcome their ailments at home or postpone seeking medical at- tention. The decrease during holidays is consistent with a study from the UAE, in which during Ramadan, one of the main holidays for Mus- lims, a significantly lower rate of visits was seen [27]. This is in contrast to a study from Turkey, a more secular Muslim country, that showed an increase in ED visits during Aid-Al-Adha, another main Muslim holiday [28].

For infectious causes, a dramatic decrease in ED visits during the

COVID-19 quarantine period was seen compared to its control group (p < 0.001). This decrease, however, might also be attributed to the fear and strict instructions of the quarantine mentioned previously, and may have also been affected by the use of masks, imposed physical distancing, and the closing of schools, stores, and many workplaces, un- intentionally leading to lower rates of contraction of other diseases. Similarly, two studies showed physical distancing executed for the COVID-19 was able to diminish the community spread of the influenza virus [29,30]. Moreover, a distinctive decrease in communicable condi- tions, including influenza, upper respiratory tract infections, otitis media, and symptoms of nausea and vomiting were demonstrated in an additional study [12]. To the contrary, Hartnett et al. found four times higher infectious-related visits to the ED during the pandemic [23]. Interestingly, during holidays a statistically significant decrease in ED-visits was also demonstrated (p = 0.004), though one might as- sume that family and friends’ parties in closed spaces during holidays and weekends would contribute to the spread of infectious diseases.

For cardiac causes, including myocardial infarction, ventricular

tachycardia, and ventricular fibrillation, statistically significant lower rates of ED visits were seen during the quarantine period when com- pared to the control group and to holidays (p < 0.001 for both). For hol- idays, no notable decrease was observed compared to weekdays (p = 0.947). This decrease in seeking help for cardiac complaints was re- ported in numerous studies, one reporting a 24-43% decline in cardiac complaints during the quarantine period compared to the preceding year [31]. Metzler et al. reported a 40% decrease in the number of STEMI (ST-elevation myocardial infarction) and non-STEMI admissions during the COVID-19 pandemic in Austria [10]. In another study, 11 of 35 patients presented >12 h from the onset of MI symptoms. The

reasons for this setback included fear of COVID-19 in 27%, believing that these were COVID-19 related symptoms in 18%, and 9% of the patients did not want to burden the ED due to the pandemic [32]. A consequence of these delays could be devastating, including the inability to revascularize a STEMI due to the delay in seeking help, rather the pa- tient at risk suffering a dangerous complication with residual long- term cardiac and systemic injury [33,34].

Unfortunately, our study does not provide data on mortality caused by these delays or abstinence of seeking help for complaints including chest pain or abdominal pain. It is only reasonable to assume that some people postponed the timing-dependent treatment, thus leading to additional morbidity. In a study conducted in Israel concerning the changes in non-COVID adult ED visits and associated mortality, a sub- stantial excess in mortality was observed during the pandemic, being highest during the first lockdown (30-day mortality rate of 54.38 per 1000 visits during the first lockdown compared to the baseline of

41.10 per 1000 visits) [35]. An Italian paediatric study presented 12 cases of delayed access for help resulting in patients’ deterioration, seven of them had to be admitted to the ICU, and four of them died. Par- ents reported avoiding reaching the hospital due to the fear of infection, and in some cases felt discouraged by health providers to visit hospitals due to the possible risk of infection with COVID-19 [8].

    1. Study strengths and limitations

A strength of our study is the scanning of over 134 million records, and the comparison to a parallel period of seven years. This renders our data more robust.

Our study had some limitations; first, this is a retrospective single- centre study, with some missing data, including duration of symptoms, the Severity of disease, the need for admission, and morbidity and mor- tality rate. An additional limitation was the selection process of the rel- evant ICD-9 code in patients who had multiple codes assigned. In these cases, we needed to decide on one diagnosis that is most representative of the cause of the ED visit. This decision was difficult in cases where several unrelated ICD-9 codes were written; for instance, cardiac and gastrointestinal complaints for the same patient. As mentioned previ- ously, the decision was based on how urgent the complaints were. Nonetheless, in 682 cases, the patient’s medical file required reviewing in order to select the most appropriate diagnosis. The process was per- formed by a single person, adding to this limitation. Moreover, although we included most of the codes that we know are used in the ED setting, some may have been absent from our list. Finally, we cannot know whether patients who could have visited the ED might have gotten the proper treatment in time.

  1. Conclusions

Significantly lower rates of ED visits were demonstrated during the COVID-19 quarantine period, compared to preceding years and main holidays and weekends, a decrease that was also demonstrated for urgent life-threatening causes. We postulate that fear and confu- sion concerning symptoms seemed to be the main causes for this de- crease, together with social distancing that affected other infectious diseases. It is our responsibility as healthcare providers to address patients’ anxiety and spread health awareness to prevent non- COVID-19 diseases spread, especially urgent ones. Our findings can be used to inform a wide range of stakeholders, including regional planners, historians, sociologists, and international healthcare orga- nizations. Regional planners can use our findings to develop strate- gies to improve the coordination of healthcare services across regions. Historians can use our findings to understand the impact of the pandemic on society. Sociologists can use our findings to under- stand the social and economic consequences of the pandemic, and in- ternational healthcare organizations can use our findings to develop strategies to improve global health security.

Author contribution

Conceptualization: OR. Coordination data collection: OR. Data man- agement: AD. Methodology: AD, OR. Formal analysis: AD, OR. Visualiza- tion: AD, OR. Writing–original draft: AD. Writing–review and editing: OR.

Financial support

None.

Funding

None.

Ethical statement

The Galilee Medical Center IRB provided ethical approval for this study (NHR10620).

CRediT authorship contribution statement

Amani Daoud: Writing – original draft, Visualization, Investigation, Formal analysis, Data curation. Ohad Ronen: Writing – review & editing, Visualization, Validation, Supervision, Project administration, Methodology, Investigation, Conceptualization.

Declaration of Competing Interest

The authors have no relevant financial or non-financial interests to disclose.

Acknowledgements

The authors wish to thank Dr. Marshall Deltoff for editorial assis- tance and Mrs. Orly Yakir and Rania Faris for the statistical analysis.

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