References
Giostra, F; Mirarchi, MG; Farina,1G; Paolillo,C; Sepe, C; Benedusi, F; Bellone, A; Ghiadoni, L; Santini, M; Barbieri, G; Guiddo,G; Riccardi, A; Lerza, R; Coen, D. (2021) Impact of COVID-19 pandemic and lockdown on emergency room access in Northern and Central Italy, Emergency Care Journal, 17: 9705
At a glance
The COVID-19 infection has spread rapidly in northern Italy since February 2020. The increase in hospitalizations of patients affected by COVID-19 led to a dramatic decrease in the admissions to the Emergency Department of patients suffering from other pathologies. In the retrospective study presented, this phenomenon is analyzed both in terms of reduced access to the Emergency Departments in Italy, and in terms of the triage priority color code assigned based on severity of the patient’s condition. These changes represent another dramatic side of the current pandemic.
What is already known
The Coronavirus pandemic has profoundly changed the life of each of us from many points of view, including the use of Health Services, especially in relation to problems not attributable to Covid itself (1) (2). Northern Italy was hit hard beginning late February 2020, with peaks in March and April. Hospitals faced a large increase in admissions of COVID-19 patients, accompanied by a drastic decrease in admissions to the Emergency Room for other pathologies. The factors that played a key role in this trend were certainly both the advice from Health Authorities to avoid the Emergency room if not for urgent necessity, and the fear of being infected.
Characteristics of the study
The retrospective observational study in question was conducted by the Academy of Emergency Medicine and Care (AcEMC), with the aim of analyzing the phenomenon and measuring both in qualitative and quantitative terms which types of patients markedly avoided accessing the emergency service during the period under review (March – April 2020).
The data collected were compared to those of the same time period in the year 2019.
The study involved 5 hospitals in Northern and Central Italy (Bologna, Brescia, Milan, Pisa and Savona).
Specifically, the following variables were identified:
– total number of hospital accesses and subdivision by triage priority color code;
– total number of hospitalizations of patients from the Emergency Room and admissions to the Department of Cardiology;
– number of triage macro-diagnoses, such as trauma, burns, chest pain and abdominal pain.
Main results
Out of a total of about 35,000 monthly accesses, hospital visits were reduced by more than 50% during lockdown. In the following months of May and June 2020, there was a recovery that was clearly below the previous year’s number. While the red codes remain stable over time, there is a dramatic collapse of the white and green triage codes, as well as a slight reduction of the yellow triage codes.
The total number of hospitalizations from the Emergency Department, during the two months of lockdown, was reduced by about 20% when compared to the same period in 2019 (Fig. 2A). An even more marked reduction (30%) can be seen in the numbers of accesses to the Department of Cardiology (Fig. 2B). The same can be said for trauma (a decrease of 80%), as well as for abdominal and chest pain (70 and 60%, respectively).
The parameters measured tend to rise in the months following the lockdown. They do not, however, reach the values of those from the same months in 2019.
The data clearly reveal how the pandemic has conditioned access to the emergency room for the populations of Northern and Central Italy, with a uniform distribution in the analyzed hospitals. This result suggests that the hypothesis may also be generalized to other hospitals in Italy. The fear of getting infected has especially affected individuals who probably would have required less intensive care, such as that of white and green triage codes.
It is also interesting to observe the reduction in cases of multiple trauma. Such a reduction can easily be attributable to lockdown, which significantly reduced risk of traumatic events such as car, sports or work accidents. On the other hand, the decrease in accesses due to abdominal and thoracic pain is more worrying. Neglecting such pain is potentially dangerous for the patient and may result in delays in treatment and diagnosis.
Another consideration is that the drastic reduction of white and green codes may be symptomatic of the prevalence of inappropriate use of the emergency department.
What’s new? Focus on elder care
This is certainly an innovative study, which focuses attention on an issue relating to the use of emergency services by the general population and how the pandemic has effectively distanced patients in need of help. This has been demonstrated in other studies focusing on the lack of access to health care by patients with Acute Coronary Syndrome.
Worldwide, the marked reduction in access to health services during the pandemic was also highlighted by a study published in 2021 . The abandonment by the elderly population (over 65) in the Veneto region is dramatic, with a decline of 25.3% in accesses to the Emergency Room between 2019 and 2020, especially those related to white or green codes. Along with the reasons previously indicated, elderly persons are also influenced by factors such as poor self-sufficiency and are consequently further disadvantaged by restrictions of public transport.
A large study developed on 33 countries, based on data collected from January 2019 to November 2020, highlighted how the greatest decline in access to the emergency room was due to myocardial infarction, stroke and sepsis, especially for those over 75. This was in turn associated with a reduction in hospitalizations. There was also an initial increase in deaths recorded in the Emergency Department, followed by a subsequent reduction in numbers, especially for the elderly and over 75.
These data are a cause of great concern given the frail elderly’s increased risk of unfavorable outcomes. Such outcomes are closely linked with the timeliness of intercepting a health problem in order to guarantee immediate treatment and diagnosis.
Edited by Chiara Gallione
References
- Jeffrey MM, D’Onofrio G, Paek H, et al. Trends in emergency department visits and hospital admissions in health care systems in 5 states in the first months of the COVID-19 pandemic in the US. JAMA Int Med 2020; 180:1328–33
- Rosenbaum L. The untold toll: the pandemic’s effects on patients without COVID-19. N Eng J Med 2020; 382:2368-71
- De Filippo O, D’Ascienzo F, Angelini F. et al, Reduced rate of hospital admissions for ACS during COVID-19 outbreak in Northern Italy. N Eng J Med 2020; 383:88-9
- Bardin, A.; Buja, A.; Barbiellini Amidei, C.; Paganini, M.; Favaro, A.; Saia, M.; Baldo, V. Elderly People’s Access to Emergency Departments during the COVID-19 Pandemic: Results from a Large Population-Based Study in Italy. J. Clin. Med. 2021, 10, 5563. https:// doi.org/10.3390/jcm10235563
- Janke, AT; Jain, S; Hwang, U; Rosenberg, M; Biese, K; Schneider, S; Goyal, P; Venkatesh, AK. Emergency department visits for emergent conditions among older adults during the COVID-19 pandemic. Journal of the American Geriatrics Society. 2021; 69:1713–1721. DOI: 10.1111/jgs.17227
