Unseen Cases

As COVID-19 surged, emergency department visits declined

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This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.

During the early days of the COVID-19 pandemic in New England, emergency department visits for medical emergencies, including psychiatric problems, trauma and heart attacks, declined by nearly a third, according to a new study by Harvard Medical School investigators at Massachusetts General Hospital.

The findings, published in the American Journal of Emergency Medicine, raised concerns among clinicians that critically ill patients were not seeking the care they needed for fear of coronavirus infection, with implications for both public health and health system planning.

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Comparing emergency department (ED) visits in two major urban hospitals and three community hospitals in the Mass General Brigham system for the months of March and April 2020 with the same period in 2019, the research team found that ED volumes—the total number of patients treated—declined by 30.9 percent from one year to the next.

The health system experienced decreases in nearly all non-COVID-19 conditions presenting to EDs during the initial phase of the pandemic, including those requiring specialty consultation and urgent inpatient procedures, according to the authors.

“While more people with less serious conditions may have stayed away from the emergency department, many cases that we would not have expected to decrease went down as well,” said study first author Joshua Baugh, HMS clinical fellow in emergency medicine at Mass General.

“For example, people requiring catheterization of their hearts for potential heart emergencies, people requiring appendectomies for appendicitis, people requiring consultation for an acute psychiatric episode,” he continued. “Across the board we saw that patients with other conditions weren’t coming in at the rate that they usually do.”

As was widely reported at the time, some patients who might otherwise have sought care for nonemergency conditions opted not to go to a hospital out of fear of contracting COVID-19 during the first surge of the pandemic, and some may have sought care at primary care practices or urgent care clinics.

“Some of the changes we saw may have been attributable to reductions in risk from lockdowns, people driving less and being outside less, but we don’t think that lifestyle changes adequately account for the full effect that we saw,” Baugh said.

“Obviously, we saw many more patients with COVID-19 who otherwise wouldn’t have been there,” said senior study author Sayon Dutta, HMS assistant professor of emergency medicine at Mass General. “And a lot of the resources that those patients needed were available because those other patients did not show up. So, this expectation that COVID-19 would add to the overall hospital volume or emergency department volume didn’t turn out to be true.”

The retrospective study included data on all ED patients at five hospitals in the Mass General Brigham health system. The hospitals included Mass General and Brigham and Women’s Hospital, both quaternary-care referral hospitals with designated centers of excellence for emergency care of patients with trauma, heart attacks and strokes. The three other hospitals were community-based centers including one that is a designated level-three trauma center, heart attack center and stroke center, and two others that are designated stroke centers.

The investigators drew on electronic health records for data on patient demographics, Emergency Severity Index, primary diagnosis in the ED, bedside procedures performed, subspecialty consultations requested and related procedures occurring during each patient’s hospital stay.

Adapted from a Mass General news release.