Emergency department presentation changes due to the coronavirus disease pandemic in Nova Scotia, Canada

Tara Dahn, Patrick T. Fok, Hana Wiemer, Daniel J. Dutton, Valancy Cole, David Lewis, Tong Liu, Keith R.

Brunt3, Robert Hanlon3, Jacqueline Fraser4, Chris Vaillancourt4,5, Paul Atkinson3,4,5

1 Department of Emergency Medicine, Dalhousie University, Halifax B3H 3A7, Canada

2 Department of Community Health and Epidemiology, Dalhousie University, Saint John E2K 5E2, Canada

3 Dalhousie Medicine New Brunswick, Saint John E2L 4L5, Canada

4 Department of Emergency Medicine Level One, Saint John Regional Hospital, Saint John E2L 4L2, Canada

5 Department of Emergency Medicine, Horizon Health Network, Saint John E2L 4L2, Canada

Multiple studies have reported decreased emergency department (ED) patient volumes during the coronavirus disease (COVID-19) pandemic,[1-6]including areas most affected by the virus.[7]Most existing studies have investigated general trends in ED presentations and have not examined the impact of COVID-19 on different types of EDs, specific ED patient groups, or illness presentations. This study is a retrospective observational study of changes in ED volumes during the first wave of the COVID-19 pandemic in Nova Scotia (NS). NS is an Atlantic Province in Canada with a population of 979,351.[8]The Government of NS declared a state of emergency on March 22, 2020, to help contain the spread of COVID-19. By June 22, 2020, the end of the first wave of COVID-19 in the province, there had been a total of 1,061 cases of COVID-19 and 65 deaths from the disease.[9]

METHODS

We retrospectively investigated the utilization of 35 EDs in NS (1 Level 1/teaching ED, 10 Level 2/community EDs, 9 Level 3/rural EDs, and 15 Level 4/small rural EDs) during the 50 days before and after the declaration of the state of emergency (February 1 to May 10, 2020), as well as the same time frame from 2019. For each patient presentation, we collected age, sex, presenting complaint, Canadian Triage and Acuity Scale (CTAS) score, and ED visit outcome (admission, transfer, discharge, or death in ED). Selected presenting complaints were classified into either “high-acuity”, “standard” or “low-acuity” using a modified Delphi consensus survey previously reported by this group.[10]Changes in presentations were analyzed using a difference-in-difference approach. There were incomplete data for presenting complaints for all Level 4 EDs and therefore they were excluded from the analysis for changes in presenting complaints.

RESULTS

The total number of ED visits decreased by 40% during the pandemic time period (from March 22 to May 10, 2020) compared to the similar time period from 2019 (baseline), with 46,467 total visits compared to 77,445. Level 1, 2, 3 and 4 ED visits decreased by 30%, 36%, 45% and 60%, respectively. The mean age of patients presenting to the ED increased significantly during the pandemic period from 46.1 to 50.6 years old. Average CTAS score showed a significant increase in higher acuity presentations during the pandemic, with a higher proportion of CTAS 1 and 2 scores relative to CTAS 3, 4 and 5 scores (18.2% CTAS 1 and 2 scores during the pandemic period compared to 15.9% in 2019). The percentage of patients admitted to the hospital from the ED significantly increased during the pandemic period (9.3% compared to 7.1% in 2019). When separated by ED level, the percentage of patients admitted (or transferred to a higher level facility) was significantly higher at Level 1, 2 and 3 EDs during the pandemic period compared to the baseline period in 2019, but not significantly different at Level 4 EDs.

High-acuity, standard, and low-acuity presentations to NS EDs decreased significantly during the pandemic time period, with decreases by 26%, 29% and 40%, respectively (Figure 1). Although overall high-acuity presentations decreased during the pandemic time period, there were several specific high-acuity presenting complaints that did not significantly decrease, including cardiac arrest, symptoms of stroke, major trauma, altered level of consciousness, seizure, and eye pain. All other high-acuity presentations significantly decreased during the pandemic period, including shortness of breath, chest pain, head injury, depression/suicide, palpitations, syncope, allergic reaction, urinary retention, and overdose.

Figure 1. Daily ED visits over time for high-acuity (A), standard (B) and low-acuity (C) presentations. Combined data from Level 1, 2, and 3 EDs. ED: emergency department.

Presenting complaint data separated by ED level differed from the pooled data. The ten Level 2 EDs had significant decreases in daily presentations for high-acuity, standard, and low-acuity complaints over the pandemic period compared to the baseline period (29%, 32%, and 40%, respectively). The nine Level 3 EDs also had significant decreases in daily presentations for high-acuity, standard, and low-acuity presenting complaints (37%, 32%, and 51%, respectively). The province’s only Level 1 ED showed similar significant decreases in daily high-acuity and standard complaints over the pandemic period (19% and 27%, respectively). However, low-acuity presentations did not decrease significantly over the pandemic period at the Level 1 ED (13%).

DISCUSSION

We observed a sharp decline in patient presentations to EDs in NS during the first wave of the COVID-19 pandemic. We saw a concerning decrease in standard and high-acuity presentations, as well as in low-acuity presentations. There were similar volumes of patients presenting with certain true emergency high-acuity presenting complaints such as cardiac arrest, stroke, and seizure, indicating that the prevalence of these events was not impacted by the COVID-19 pandemic. However, patients presenting with other highacuity complaints, such as chest pain, shortness of breath, and syncope significantly decreased. There is a concern that delays in seeking medical attention for potentially critical symptoms may result in increased morbidity and mortality. Our demographic data also reflects that patients may have had a higher threshold to seek treatment in an ED during the pandemic period, with the average patients being older, with a higher average CTAS score, and with a larger proportion requiring admission.

The likelihood of patients presenting to the ED during the COVID-19 pandemic was not uniform across all ED levels. The only Level 1 ED did not have a significant decrease in low-acuity presentations during the pandemic period, whereas the Level 2 and Level 3 EDs saw significant decreases in low-acuity visits. The Level 1 ED is located in the provincial capital, Halifax, and serves mostly an urban population. During the first wave of the pandemic, many walk-in clinics closed, possibly contributing to more patients presenting to the Level 1 ED for low-acuity problems. The Level 2 and Level 3 EDs have far fewer surrounding walkin clinics, and therefore fewer patients accustomed to relying on them for care.

Level 3 EDs experienced a greater decrease in high acuity presentations (37%) compared to Level 1 and Level 2 EDs (19% and 29%, respectively). It is possible that patients in rural areas had a higher threshold to attend the ED due to highacuity complaints during the pandemic compared to patients from urban areas.

The striking decreases seen in ED presentations in our study, as well as around the world, are likely multifactorial. Lockdowns and stay-at-home orders may have limited some high-risk activities, accidents, and spread of disease. However, interviews with patients have indicated that fear and misinformation have also played a role in the decrease in ED presentations.[11-12]Some regions have begun to report data suggesting an increase in non-COVID-related morbidity as a result of the COVID-19 pandemic. Tam et al[13]reported an increased delay between symptom onset and first medical contact for ST-elevation myocardial infarction (STEMI) patients in 2020 compared to 2019. Lo et al[2]reported a significant increase in out-of-hospital cardiac arrest during the pandemic period compared to 2019 in Taiwan, China, a region that had very few COVID-19 cases and a total of only seven COVID-19-related deaths, raising concern that people were possibly delaying seeking care for critical illness. International mortality data have suggested this as well, with many countries reporting greater numbers of deaths in 2020 than would be expected, even when COVID-19 deaths are taken into account.[14]In contrast, reports in the paediatric literature have shown no significant delays in patients seeking care for serious illnesses during the pandemic.[15]It will be important for future research to continue to examine the impact of the COVID-19 pandemic on non-COVID-19-related morbidity and mortality.

Limitations include data that were retrospectively collected and based on census data alone. Due to incomplete data for presenting complaints for many Level 4 EDs, all Level 4 EDs were excluded from the analysis on presenting complaints, which limited the generalizability of our results around presenting complaints to smaller, rural EDs. Another limitation was that data were not available from the IWK Health Centre, the province’s tertiary care pediatric hospital, so our conclusions were limited to non-pediatric presentations.

CONCLUSIONS

In the early stages of the COVID-19 pandemic, ED presentations for high-acuity, standard, and low-acuity complaints decreased significantly in NS, a region with low rates of COVID-19. Changes in high-acuity and lowacuity presentation rates varied by locations and types of EDs. Though a decrease in ED presentations cannot be uniformly classified as a negative outcome, for example, some patients who chose not to present may have had minor complaints, many of the decreased presentations were for potentially critical complaints (i.e., chest pain, shortness of breath). It is important that studies continue to focus not only on the direct effects of COVID-19 but also on the indirect effects on non-COVID-19-related morbidity and mortality. It is important that hospitals and the government continue to work on improving: (1) public communication strategies to ensure that patients continue to present to the ED if they are having potentially serious symptoms; and (2) non-ED access to medical care for low-acuity complaints during a pandemic.

Funding:There was no funding support for this study.

Ethical approval:This study was approved by the Nova Scotia Health Research Ethics Board (1025914).

Confl icts of interest:The authors state no confl ict of interest and have received no payment in preparation of this manuscript.

Contributors:TD proposed the study and wrote the paper. All authors contributed to the design and interpretation of the study and to further drafts.