COVID-19: “startling” change in emergency presentations – the numbers are down but the complexity is up

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Emergency physicians have noticed a startling change to the types of presentations to EDs since the beginning of the COVID-19 pandemic. The number of people attending Australian EDs in 2020 was significantly lower than 2019, but workload hasn't dropped with more complex patients being treated, according to a research letter published in the MJA.

Image courtesy of SCHHS

Reduced non-COVID-19 ED numbers have been observed around the world, both anecdotally and through studies, compared with the same period last year. According to Dr Shyaman Menon, Clinical Director of Emergency at Peninsula Health in Victoria, the absolute numbers are down. “But if you delve into the profile of the patients coming in and what they need and what’s happening in society, then some EDs are seeing more complex patients and the workload hasn’t dropped. More complex patients need more time, more services and more thought processes,” he said.

Increased complexity and acuity was also reflected in the MJA research letter. 

The research analysed ED presentation numbers at Western Sydney Health Local Health District from 29 March to 31 May in both 2019 and 2020. It found that overall, the number of ED presentations was almost 25% lower in 2020 than they were in 2019. Presentation numbers were lower for all categories from emergency to non-urgent; however, they were up 14% for category 1 (resuscitation). 

One of the study authors, Dr Andrew Kam, is concerned this trend is likely to continue. “I think we will find people’s conditions have been brewing in the community and we will see some presentations of more serious conditions as the pandemic eases," he said.

Dr Menon agreed that uncontrolled chronic conditions will likely become a focus in the next 12 months. “EDs will see the downstream effect of some conditions like uncontrolled hypertension, uncontrolled sugar, uncontrolled chronic kidney and lung disease,” he said. 

Melbourne hospitals have the unique experience of two lockdowns and many report seeing reduced emergency attendance through both. However, according to Dr Andrew Walby, Director of Emergency at Melbourne’s St Vincent’s Hospital, “the reduced attendance numbers in the second lockdown have been less significant than the first wave”. 

Dr Walby speculated that people who didn’t come to hospital in the first wave perhaps realised they did need to come to hospital. These borderline cases were reflected in the research letter. 

There were lower numbers of presentations of people with chest pain or stroke in 2020, a statistic that has also been reported overseas. “We’re concerned that we’re only seeing the fringes of cases of higher acuity presentations such as stroke presentations,” said Dr Kam. “While incidence may have decreased, it seems more likely that those patients are simply not presenting when they need help the most.” 

Overseas, researchers have speculated that a decrease of stroke presentations could have something to do with people being less active and therefore putting less strain on their heart. 

Dr Kam noted that we won’t know why these numbers decreased until more studies have been done after the pandemic. 

In EDs, diseases such influenza and community-acquired pneumonia haven’t presented as much this year. In Melbourne, there have also been less musculoskeletal injuries due to less sport, less alcohol-related injuries and reduced car accident trauma. 

Dr Menon noted that there has been a significant change in Peninsula Health’s paediatric ED. “We aren’t seeing gastroenteritis, paediatric bronchiolitis, and influenza has dropped both in adults and paediatrics. A lot of that is to do with social distancing.” 

One area of concern was the increase in mental health presentations. The MJA study noted that it “may reflect anxiety about COVID-19, loss of job security or prolonged isolation”. 

Doctors said it also could be affected by a fear of accessing other care providers due to COVID-19. Dr Menon said “it’s not just EDs, people are afraid of going to GPs for similar reasons.” 

Dr Kam agreed that often people aren’t able to access their GP, which leaves them at a loss of where to go until they’re at a crisis point. “Because the pandemic has limited access to those primary care facilities which are their normal first points of call, issues might not be picked up early or patients might not know how to access specialist care otherwise,” he said. 

Clinicians wanted to reassure people that not seeking help for any health issue was a bigger risk than the chance of infection. 

Dr Menon believes one good thing that has come from the pandemic is the increased access to telehealth. There’s hope that it will continue to change the future of health care delivery. “We’ve shown that care can be delivered in a different setting. No one wants a patient in the ED. If I can provide treatment then and there, then I’d like to be able to provide it. As a community, if we realise we can seek alternative treatment options, that frees up the emergency clinicians for those who need it,” he said. 

For emergencies though, ED doctors want people to know it’s safe to come to hospital. “We want people who need to be there to be there,” Dr Walby said. 

 
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