COVID-19 lock-down significantly reduced the number of surgical presentations in an emergency department

doi:10.21203/rs.3.rs-81925/v1

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COVID-19 lock-down significantly reduced the number of surgical presentations in an emergency department

https://doi.org/10.21203/rs.3.rs-81925/v1

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published 28 Jan, 2021

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Introduction

Coronavirus disease 2019 (COVID-19) is an acute virus infection that was declared by the World Health Organization (WHO) as a pandemic. As a consequence, the Swiss government decreed a public lock-down to reduce and restrict further infections. The aim of this investigation was to provide the impact of the COVID-19 lock-down on the presentations of patients in an interdisciplinary emergency department (ED).

Patients, Materials and Methods

A retrospective study was performed at an interdisciplinary Swiss ED during the lock-down period. All patients who presented to the ED were enrolled in this investigation and compared to a control cohort during the same time period in 2019. Data regarding patient characteristics, medical specialty, time course of presentations during the observation period, and outpatient or hospital admission were analyzed.

Results

In total, 7,072 patients were included in the final analysis. During the lock-down period, the number of ED presentations significantly decreased by 29% in comparison to the control period in the previous year (p<0.0001). The analysis of the time course revealed that in each week, the number of patients was lower, with a 13% to 43% reduction. Irrespective of the medical specialty, the number of presentations decreased during the COVID-19 situation, whereas this decrease was higher in surgical diseases (31%, p<0.0001) than in non-surgical presentations (3.6%, p=0.4).

Discussion

The socio-economic lock-down impacted the number of presentations in an ED. Mainly, surgical diseases and injuries were affected in terms of a reduction of presentations during the COVID-19 lock-down period.

Critical Care & Emergency Medicine

COVID-19

emergency department

medicine

surgery

pandemic

Coronavirus disease 2019 (COVID-19) is an acute virus infection of the respiratory tract with reported mild to severe courses [1, 2]. In contrast to severe acute respiratory syndrome (SARS), which is caused by SARS coronavirus (SARS-CoV), the viral load in COVID-19 (SARS-CoV-2) was higher and more often detectable by nasopharyngeal swabs; therefore, active viral replication in the upper respiratory tract was suggested [1]. Prolonged viral shedding from the sputum leads to high and effective transmission of SARS-CoV-2 and impacts the control of infections. In several countries, patient care is unsustainable due to the high number of acute COVID-19 infections, so emergency departments and ICUs collapse under the flood of patients. Therefore, several preparations are necessary, such as excellent communication, immediate triage of potentially infectious patients, definition of treatment and diagnostic algorithms to identify patients with risk factors as well as suitable protection devices for hospital personnel [3].

Since the first reports of COVID-19 late in 2019 as an epidemic infection [4, 5], the extension of COVID-19 became a worldwide public health emergency, so that the World Health Organization (WHO) declared COVID-19 on March 11, 2020, as a pandemic [6]. As a consequence of this fact and increasing infection rates, the Swiss government, as many other governments worldwide, decreed a public lock-down to reduce and restrict further COVID-19 infections on March 13, 2020 (effective as of March 14 2020) by restraining public life to avoid intense social contacts and to interrupt chains of infection.

Due to the severe spread of COVID-19 and to redistribute manpower and hospital resources, elective surgeries were reduced or even cancelled except for specific urgent interventions [7, 8]. The main goal of this restriction was to maximize the hospital and ICU beds and to shift manpower towards the diagnosis and acute treatment of COVID-19 patients. Furthermore, these acute changes in hospital utilization should reduce the unnecessary exposure of patients and healthcare workers with potentially positive but asymptomatic COVID-19 carriers.

There are reports that in some medical specialties, such as dermatology [9], orthopedics [7], cardiology [10], urology [11], and neurology [12], the treated emergency cases during the COVID-19 pandemic were reduced in comparison to prior time periods. A possible explanation for this fact might be that not the incidence of certain diseases decreased during that time, but patients were afraid of infection and avoided attending hospitals for further diagnosis and treatment [10]. Furthermore, reports from Spain and Hong Kong showed that in the case of a cerebral stroke, not only was the number of treated cases reduced but also the arrival time and start of treatment was delayed [12, 13].

The aim of this retrospective investigation was to provide an overview of the impact of the COVID-19 lock-down on the presentations of patients in an interdisciplinary Swiss emergency department (ED). To the best of our knowledge, this is the first investigation, in a rapidly evolving field of science, on the influence of COVID-19 public lock-down on the number of presentations in the emergency department of a large public hospital in Switzerland.

A retrospective study was performed at an interdisciplinary Swiss ED with approximately 35,000 consultations per year. The spectrum of treated patients ranged from emergencies in general internal medicine, including subspecialties (e.g., cardiology, nephrology, gastroenterology), surgery, orthopedics, traumatology, neurology, urology, gynecology, and otolaryngology.

During the governmental instituted lock-down between March 14, 2020 and April 26, 2020, all patients who presented to the ED were enrolled in this investigation. As a control cohort, all patients during the identical time period in 2019 were included in this analysis.

Data regarding patient characteristics (age, gender), medical specialty (non-surgical specialties including general internal medicine, cardiology, nephrology, neurology; surgical specialties including general surgery, visceral surgery, orthopaedics, thoracic surgery, vascular surgery, gynaecology, otolaryngology, urology), time course of presentations during the observation period, and outpatient or hospital admission were collected and compared between the two time periods.

Our ED consists of a fast track ED and an interdisciplinary ED. The differences between these units are the opening hours and the severity of diseases of the treated patients. The fast track ED mainly covers patients between 8.00 am and 11.00 pm with emergency severity scores (ESIs) 4 and 5, whereas the interdisciplinary ED is open 24/7, covering patients with ESI triage levels 1-3.

Statistical analysis

Continuous variables were reported as the mean and standard deviation or median and interquartile range as appropriate. Comparison of the groups was performed using Student’s t test. Categorical variables were reported as proportions and compared with the χ² and Fisher exact test. Statistical analysis of the data and graphics were performed with the GraphPad Prism 5.0 software package (GraphPad, San Diego, California, USA), and p≤0.05 was assumed to be statistically significant.

Ethical considerations

Ethical committee approval was obtained for this retrospective study from the Ethics Committee of North-West and Central Switzerland (No. 2020-01359), and the need for individual patient consent was waived.

In total, 7,450 patients were included in this investigation. In addition, in a specific COVID-19 ambulatory setting off site of the ED, 994 patients were tested by nasopharyngeal swab for COVID-19 during the lock-down period. After exclusion of patients with missing data and patients under 18 years of age, 7,072 patients were included in the final analysis. During the lock-down period, the number of ED presentations significantly decreased by 29% in comparison to the control period in the previous year (2019 n=4'127 vs. 2020 n=2'945; p<0.0001). The decrease in consultations was even higher in the fast track ED (2019 n=1'639 vs. 2020 n=875; 46% decrease; p<0.0001) than in the interdisciplinary ED (2019 n=2'488 vs. 2020 n=2'070; 17% decrease, p<0.0001).

The analysis of the time course during the lock-down of six weeks revealed that in each week, the number of patients was lower during lock-down than in the corresponding week the year before (Fig. 1). In the second week, the percent decrease was 43% and thus higher than in the other weeks, and in the first week, the smallest reduction was seen with 13%.

Between the two time periods, there were no statistically significant differences concerning age (2019 52.1 ± 21.4 years vs. 2020 52.7 ± 20.8 years; p=0.2) or gender (2019 females 49.6% % vs. 2020 females 49.9%; p=0.9). There was no significant difference in the necessity of hospital admissions between the two time periods (2019 n=1'084, 26.3% vs. 2020 n=829, 28.1%; p=0.2).

Irrespective of the medical specialty, the number of presentations decreased during the COVID-19 situation. The decrease in presentations due to surgical diseases was 31% (2019 n=1'181 vs. 2020 n=810, p<0.0001) and therefore much higher than in non-surgical presentations with 3.6% (2019 n=1'307 vs. 2020 n=1'260, p=0.4).

There was a significant decrease in presentations in the ED during the socio-economic lock-down due to COVID-19 in Switzerland. This decrease was obvious in all investigated medical specialties but was mainly present in surgical diseases independent of COVID-19.

The avoidance of many patients to refer to the hospital and potential infection with COVID-19 might be one possible explanation for this decrease. However, the decrease was seen in all medical conditions that require inpatient care and emergency treatment, as there were no differences in the necessity of hospital admissions. This fact leads to major concerns about the well-being of the general population during this lock-down situation.

Immediately after the governmental edict of social restriction, the numbers of ED presentations decreased, but the reduction was essentially obvious after week 2 and remained on the same level during the entire observation period. The reduction of presentations to our ED was even higher than in a previous report from England with 25% [14]. Interestingly, the decrease in presentations to our fast track ED was twice as high as that in the interdisciplinary ED. Many patients treated in fast-track ED present medical issues, which can be considered bagatelles and often can be treated by a family physician. This reduction might be explained by a general fear of getting infected with COVID-19 in a hospital and the recommendation to visit an ED only in severe alteration of the health condition to prevent an overload of hospital employees and health resources [14].

The impact of reduction was more obvious with surgical presentations, which may be explained by a reduction of traffic accidents, work injuries, leisure accidents, and reduced violent crime incidence due to social distancing [15]. Nonsurgical presentations were not affected to the same extent, as during the lock-down period, presentations due to COVID-19-associated symptoms and diseases such as pneumonia, upper respiratory tract infections, examination for COVID-19 symptoms directed patients to the ED.

The present study is limited by its focus on one isolated ED and the lack of inclusion of local family physicians' practices. However, anecdotal reports of some local family doctors revealed comparable effects of the COVID-19 lock-down.

In conclusion, the socio-economic lock-down impacted the number of presentations in a Swiss ED. Mainly, surgical diseases and injuries were affected in terms of a reduction of presentations during the COVID-19 period. Whether this effect will remain after COVID-19 and impact the general morbidity and mortality rate in Switzerland needs to be analyzed in the future.

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by René Fahrner, Stefan Bähler, and Gregor Lindner. The first draft of the manuscript was written by René Fahrner, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conflict of interests

Gregor Lindner discloses potential conflicts of interest (consultant fees and honoraria from Bayer, Fresenius Kabi, Otsuka, Daiichi Sankyo; travel grants from GlaxoSmithKline, Otsuka, and Pierre Fabre), René Fahrner and Stefan Bähler have no conflicts of interest to disclose. None of the authors obtained funding for this specific report.

Acknowledgements

Not applicable for this study.

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Journal Publication

published 28 Jan, 2021

Read the published version in Wiener klinische Wochenschrift →

Version 1

posted

You are reading this latest preprint version

COVID-19 lock-down significantly reduced the number of surgical presentations in an emergency department

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Journal Publication

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Abstract

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Introduction

Patients, Materials and Methods

Results

Discussion

Conclusion

Declarations

References

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Journal Publication

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