The COVID-19 outbreak led to significantly reduced overall emergency room visits and hospital admissions from the ED. This decrease in patients seeking emergency medical care mainly affected medical specialties while numbers of trauma patients and emergent surgical patients dropped noticeably less. Even though statistically not significant, admissions from the ED to the ICU dropped although more ICU resources were available due to adapted in-hospital processes. This decrease of hospital admissions is alarming because not only outpatients with minor medical problems avoided ED medical care, but also inpatient numbers dropped which is supported by the ratio of outpatients vs. inpatients that remained the similar. This phenomenon – probably mostly due to patient’s fear of SARS-CoV-2 – was also described by Wong et al. and led to an increased number of cardiac arrests in the Californian region [4].
To our knowledge, our study is the first evaluating the changes on emergency care in a whole city in Europe observed during the COVID-19 outbreak. The local effects in the analyzed hospitals were very different due to the different sizes and specializations (table 1, figures 1-4).
Data from the U.S. also showed that reductions in ED visits were observed while admission to the hospital from ED increased between to 22% and 149% when the SARS-CoV-2 case rate began to increase [5]. The same effect was reported by Comelli et al. in Parma, Italy in a large urban ED [6]. These findings are in contrast to our findings, but the analyzed U.S. and Italian regions were hit much harder by the pandemic with more SARS-CoV-2 hospital admissions related to the residents. In Italy, also the incidence of prehospital cardiac arrest increased during the COVID-19 pandemic. Fear of infection with a consecutive delay in seeking medical care is also one of the possible reasons for these findings [7]. Another difference to our findings is that in a recent U.S. supra-regional study the ED visits dropped with a latency after the SARS-CoV-2 infections began to rise [8]. In the analyzed city of Moenchengladbach, ED visits declined after local media published the first local COVID-19 cases. Also in other German hospitals, reduced ED visits during the pandemic crisis were found which is also in contrast to the U.S. and Italia but data was retrieved from an ED register of mainly university hospitals which is not completely representative [1]. In contrast to this study that included data of 36 different German hospitals in different regions, the decrease of patients seeking medical care in an ED in our study dropped two weeks earlier [1]. In week 9, after the first cases of SARS-CoV-2 positive patients relating to an indoor carnival event (Gangelt, district of Heinsberg, Germany) were launched by the local press, ED visits began to drop in our city. The local press also launched that one hospital doctor in hospital 3 was infected with SARS-CoV-2.[9] Later on, media published hospital staff infections in hospital 2 [10]. This information could be one important reason for the accelerated local drop of ED visits and earlier decrease compared to other German regions [1].
Like described above, the decrease in admitted patients was mainly due to declined patient numbers in medical disciplines and much less in trauma and concerning other surgical emergency cases. Schwarz et al. also describe reduced ED visits due to cardiovascular emergencies in a German university hospital, but cerebrovascular accidents did not decrease significantly [11]. Quadri et al describe reduced laboratory procedures in Italy, even for percutaneous coronary interventions [12]. This holds the risk that even patients with an urgent need for a percutaneous coronary intervention do not seek cardiovascular medical care.
Overall, German data seem to be in contrast to the most U.S. data of COVID-19 hotspots where medical admissions from the ED increased and motor vehicle accidents decreased [5,8,13]. Also in Israel significant reductions in ED visits were observed [14]. The reduction was even more profound compared with H1N1 epidemic in 2009 in this region [14].
Working accidents dropped also in spring of 2019, especially during Easter holiday, but recovered thereafter. In 2020 the decrease in working accidents began earlier parallel to the social distancing measures like school and non-food store closures. A considerable amount of working accidents are accidents of pupils in all kind of schools or childcare facilities. Therefore, the closure of schools and kindergartens could be one explanation for the declined number of working accidents. Unfortunately, we were not able to differentiate between accidents at workplaces and accidents at schools. Nunez et al. report that ED visits for trauma, workplace accidents and road traffic accidents declined significantly compared to the same period in 2019 during the Coronavirus crisis at a tertiary hospital in Spain [15]. In many hospitals orthopedic trauma capacities were adapted (mainly reduced and/or re-organized) due to increased numbers of COVID-19 patients [16].
After a period with restaurant, non-food-store and school closure the social life in Germany came to an adapted normality during May 2020. However, the number of ED visits did not recover to the numbers of 2019. One explanation could be that people still fear to be infected with SARS-CoV-2 in hospitals.
Limitations
One major limitation is that partially data of one hospital could not be included in the pooled analysis because structured data acquisition started in 2019 during the historical control period. Therefore, all sum-curves are affected by this limitation. Our study is a retrospective data analysis with all limitations, but we did not analyze any performance or outcome data. Missing data of ED contacts and hospital admissions are very unlikely, but we cannot exclude missing data completely. Contact times and length of stay in the ED could not be analyzed due to different documentation systems and different use of time stamps. Therefore, we cannot answer the question, if the COVID-19 outbreak affected the ED treatment time span and turnaround times.