Reduction in Emergency Department Presentations in a Regional Health System during the Covid-19 Pandemic

Introduction Nationally, there has been more than a 40% decrease in Emergency Department (ED) patient volume during the coronavirus disease 2019 (Covid-19) crisis, with reports of decreases in presentations of time-sensitive acute illnesses. We analyzed ED clinical presentations in a Maryland/District of Columbia regional hospital system while health mitigation measures were instituted. Methods We conducted a retrospective observational cohort study of all adult ED patients presenting to five Johns Hopkins Health System (JHHS) hospitals comparing visits from March 16 through May 15, in 2019 and 2020. We analyzed de-identified demographic information, clinical conditions, and ICD-10 diagnosis codes for year-over-year comparisons. Results There were 36.7% fewer JHHS ED visits in 2020 compared to 2019 (43,088 vs. 27,293, P<.001). Patients 75+ had the greatest decline in visits (−44.00%, P<.001). Both genders had significant decreases in volume (−41.9%, P<.001 females vs −30.6%, P<.001 males). Influenza like illness (ILI) symptoms increased year-over-year including fever (640 to 1253, 95.8%, P<.001) and shortness of breath (2504 to 2726, 8.9%, P=.002). ICD-10 diagnoses for a number of time-sensitive illnesses decreased including deep vein thrombosis (101 to 39, −61%, P<.001), acute myocardial infarction (157 to 105, −33%, P=.002), gastrointestinal bleeding (290 to 179, −38.3%, P<.001), and strokes (284 to 234, −17.6%, P=0.03). Conclusion ED visits declined significantly among JHHS hospitals despite offsetting increases in ILI complaints. Decreases in presentations of time-sensitive illnesses were of particular concern. Efforts should be taken to inform patients that EDs are safe, otherwise preventable morbidity and mortality will remain a problem.


How does this improve population health?
This study highlights the need for widespread communication to the public regarding the safety of emergency departments and the serious implications of avoiding emergency care.
requiring immediate medical attention, have decreased as well. [6][7][8] Investigators in Italy reported an increase in out-of-hospitalcardiac arrests (OHCA) that appears strongly correlated with an increasing incidence of COVID-19 in the community. 9 Similarly, in California, EMS reported sudden increases in out of hospital cardiac arrests (OHCA) in COVID-19 negative patients, as well as patients arriving too late to receive tissue plasminogen activator for ischemic strokes. 4 Another Italian report highlights a significant decrease in ischemic stroke presentations at hospitals. 10 While each of these is a concern in and of itself, there has been few detailed analyses characterizing the variance in the multiplicity of patient conditions associated with the ED volume loss.
We sought to determine and characterize the change in ED presentations during a period while public health mitigation orders were in effect in Maryland and D.C. (March 16, 2020 school closures to May 15, 2020 non-essential businesses reopen in Maryland; March 24, 2020 non-essential business closures to May 29, 2020 Phase One re-opening in D.C.). [11][12][13][14][15] We compared patient volumes, demographics and clinical conditions from March 16th through May 15, 2020 to corresponding dates in 2019 for five regionally dispersed EDs in our health system.

METHODS Study Design and Setting
We conducted a multi-center retrospective observational cohort study of all registered adult ED patients presenting to any of our five Johns Hopkins Health System hospitals in the mid-Atlantic region. Four of the hospitals are in Maryland and one is in the District of Columbia. The regional hospitals include: a large inner-city academic medical center, an urban community-oriented teaching affiliate, and three communitybased non-teaching hospitals. (Figure 1) The study was accepted by the Johns Hopkins Institutional Review Board.

Study Population
All patients aged 15 years or older who presented to each of our five health-system adult EDs from March 16 through May 15, in 2019 and 2020, respectively, were included. Patients who registered but left without being seen were included. Patients younger than 15 years were excluded from the data set.

Data Collection, Outcomes, and Analysis
To identify historical patterns, patient volumes for the 2-month period of interest were obtained for the years 2016-2020 for all sites. All data were abstracted from the EPIC electronic medical records (EMR) of our institutions by an experienced data analyst. For 2019 and 2020, we collected de-identified demographic information such as age, sex, race, ethnicity, as well as presenting chief complaints, dispositions, triage assessments (Emergency Severity Index, HopScore), and primary ICD-10 codes. HopScore is an outcomes-based emergency triage system. 17 Chief complaints with fewer than 15 occurrences were compiled into the "General" category. This included the autoimmune, cancer, dialysis, endocrine metabolic, mass, and transplant categories. Trends over time in visits were calculated for each hospital. For both study periods (2019 and 2020), differences in results across all JHHS EDs was judged as relatively minor. Accordingly, aggregated data was used to identify generalizable trends and to make specific year-overyear comparisons.
Decreases from year to year were calculated both as absolute reductions and percentage changes. As the rate of visits to EDs typically follows a Poisson distribution we used the two-sided Poisson test of two means to assess whether the rate of visits over the two-month study period in 2020 was statistically discernable from 2019. [18][19][20]

RESULTS
Patient volumes from 2016 to 2019 averaged 42,775 and no year deviated by more than 1.5% over the corresponding two-month study timeframe in any other year, until 2020. In 2019, there were in aggregate 43,088 visits in all five EDs, and 27,293 for the same study time period in 2020, representing a 37% decrease (P<.001). Decreases across all five EDs ranged from 27.7% to 40.3%. (Figure 2). Similar decreases were seen across almost all demographic groups. There was a decline in visits across all age groups, with the largest decrease in those  Table 2).
Year-over-year comparisons of time-sensitive illness based on ICD-10 codes ranged from a decrease of 11   over the age of 75 (-44.00%, P<.001). During the same time period, there was a greater decrease in patients identifying as females (-41.9%, P<.001) than males (-30.6%, P<.001). There were decreases in all self-identified racial groups who had more than 30 visits. There was no appreciable difference in visits amongst those identifying as Hispanic or Latinx 0.7% (P=0.79) compared to significant declines amongst other selfidentified ethnicities (Table 1).
Most clinical conditions, with the exception of pulmonary, influenza-like illness (ILI) and penetrating trauma decreased.

DISCUSSION
Our study underscores the disturbing finding that patients with time-sensitive and critical conditions such as AMI, cardiac arrest, stroke, venous thrombotic events, and GI bleeding failed to seek emergency medical care during the period of time when public health mitigation measures were in force in Maryland and D.C. While others have highlighted a few specific conditions and general disease categories, our study included all patient clinical presentations and focused on year-over-year trends of a number of the most common time-sensitive illnesses. 3,5,[7][8][9] The rapid onset of the Covid-19 pandemic caused hospital emergency department patient volumes to plummet throughout the nation, and this trend was evident in the Maryland and Washington, D.C. metro area as well. 3 Others have provided general evidence of increased morbidity and mortality not attributable to Covid-19, including out of hospital arrest. 4-9 Based on our results, it appears likely that these previous observations were not isolated occurrences.
During the month of March, 2020, public health emergencies were declared in both Maryland and D.C., and executive stayat-home orders closing all schools and non-essential businesses were put in place. [11][12][13] Declines in ED patient volumes were subsequently seen across all age groups and genders, with the greatest decline among those 75+. Some of this decrease likely reflected public awareness of reports of increased morbidity and mortality with increasing age. 21 Additionally, in Maryland, a Johns Hopkins disaster response program called Go Team partnered with the National Guard, Maryland Department of Health, and the University of Maryland to provide stabilizing care to COVID-19 infected nursing home patients in situ which resulted in a reduction in the number of residents who required Trends in Baltimore-Washington D.C. ED Presentations During COVID-19 Mann et al.   transport to local EDs for treatment. While patient volumes fell across most racial and ethnic categories, there was no decrease seen in Hispanic or Latinx visits presenting to JHHS EDs. This is not entirely surprising since Hispanic communities in the US and our region have been found to suffer disproportionately higher rates of COVID-19 infection. Despite significant barriers to healthcare access, low rates of medical insurance, and reluctance to seek care, it should be expected that many in this community would turn to emergency care when symptomatic with a possible COVID-19 infection. [22][23][24] Corresponding to an overall volume decline, was a decrease in most clinical conditions presenting to emergency departments. The exceptions to these downward trends were increased presentations of conditions likely related to COVID-19 such as fever, shortness of breath, and respiratory infections. These complaints, which are potentially indicative of COVID-19 infection, essentially doubled during our study, further accentuating the profound decrease in virtually all other conditions. Our most worrisome finding, however, relates to the significant declines in time-sensitive disease diagnoses. Other researchers have noted similar findings and, indeed, there may be some reasonable explanations for reductions in certain, potentially life-threatening ED presentations. 3,[7][8][9][10]25 For instance, patients in isolated settings may not be exerting themselves or confronting significant stressors and, therefore, incidence of acute cardiac events may have decreased. Additionally, studies have demonstrated that people can survive undiagnosed PEs, and there is even some evidence to suggest that conditions as serious as acute appendicitis are over-treated with surgical intervention. [26][27][28][29] Taken together, these explanations may elucidate a portion of the decrease in ED volumes of life-threatening conditions. Yet, such possibilities could not reasonably account for the reductions across the numerous time-sensitive illnesses noted in this study.
A more likely explanation is that people suffered serious medical crises and failed to seek appropriate care. A recent article noted that emergency medical services (EMS) in Lodi, CA reported a 45% increase in field cardiac arrest calls, and patients with strokes were arriving too late to receive tissue plasminogen activator (tPA). 4 Even serious, COVID-19 related complications may have presented to EDs too late for lifesaving care, or patients may have died at home. In Italy, for instance, it was found that a significant percentage of patients who had out-of-hospital cardiac arrests, were also COVID-19+. 9 Researchers looking at data from the initial COVID-19 outbreak in China, observed that the inflammatory response to the virus can lead to increased rates of thrombosis. 30 This COVID-19 induced coagulopathy has likely resulted in acute myocardial infarctions, pulmonary embolisms and strokes that did not make it to an ED.
It is highly probable that public health mitigation measures substantially reduced conditions and behaviors that often result in ED visits for occupational injuries, motor vehicle collisions, non-violent trauma, and complications from elective surgeries. 31 What is more, the expansion of telemedicine services during the pandemic may have provided opportunities for ready access to medical care that previously resulted in ED visits. 32 Fear, however, likely had the greatest impact on patients failing to seek emergency care. It has been observed anecdotally that anxiety about contracting the Covid-19 infection has caused a significant number of patients to delay or avoid seeking medical care. 4,29,33 What our study has clarified is the extent to which ED patients have not sought emergency treatment for time-sensitive, potentiallyfatal, medical conditions during the Covid-19 pandemic.

LIMITATIONS
There are several limitations to our study. First, although the data included all adult patients presenting to our regional Trends in Baltimore-Washington D.C. ED Presentations During COVID-19 Mann et al.  hospitals during the prescribed time periods, as with all clinical studies, some data misclassification may have occurred. Second, data from other health systems in the State of Maryland were not analyzed and, therefore, the results of this study may not be generalizable across the state or region. While there was wide geographic distribution amongst the study sites, all hospitals were located within relatively populous areas, the Eastern Shore and Western Maryland may have had different experiences.

CONCLUSION
ED visits in our health system by patients with timesensitive conditions that should not have been influenced by the pandemic or public health orders, decreased substantially compared to a previous similar time period. We experienced a significant decline in volumes despite doubling of presentations consistent with Covid-19 symptoms. The reasons are likely multifactorial including: public health stay-at-home orders, closure of non-essential businesses and schools, discontinuation of non-emergent surgical procedures, availability of alternative care options and, perhaps the highest contributor, the generalized fear about contracting the illness.
Hospitals and public health officials need to find a way to better communicate the serious implications of refusing or avoiding emergency medical care. EDs are safe, certainly safer than congregant locations and general indoor public venues.
Until the misperception of the risks associated with seeking care at hospital emergency departments are addressed, it is likely that preventable morbidity and mortality will remain a problem.