The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study

Abstract

Background: Hospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 pandemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies.

Methods: This analysis is an observational study of ED attendances at the Imperial College Healthcare NHS Trust (ICHNT). We calibrated auto-regressive integrated moving average time-series models of ED attendances using historic (2015-2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12, 2020 (when England implemented the first COVID-19 public health measure) and May 31, 2020. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared hospital admissions made via the ED and in-hospital mortality at ICHNT during the present year to the historic 5-year average.

Results: ED attendances at ICHNT decreased by 35% during the period after the first lockdown was imposed on March 12, 2020 and before May 31, 2020, reflecting broader trends seen for ED attendances across all England regions, which fell by approximately 50% for the same time frame. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport) and not correlated with any of the spatial dependencies analysed such as increasing distance from postcode of residence to the hospital. Emergency admissions of patients without COVID-19 after March 12, 2020 fell by 48%; we did not observe a significant change to the crude mortality risk in patients without COVID-19 (RR 1.13, 95%CI 0.94-1.37, p = 0.19).

Conclusions: Our study findings reflect broader trends seen across England and give an indication how emergency healthcare seeking has drastically changed. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of patients without COVID-19 did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown. National analyses and strategies to streamline emergency services in England going forward are urgently needed.

Keywords: Accident; And emergency; COVID-19; Emergency department.

Fig. 1

Time series of attendances to ED services at ICHNT (Charing Cross Hospital and St Mary’s Hospital) in relation to the regional (all London EDs) decline in attendances. Data for COVID-19 deaths in background bar chart as collated from daily Public Health England reports into publicly available repository, available at: https://raw.githubusercontent.com/tomwhite/covid-19-uk-data/master/data/covid-19-totals-england.csv

Fig. 2

Attendances by geographic area of patient residence to (a) Charing Cross and (b) St Mary’s hospitals between March 12 and May 31. The maps show A (< 1000 m), B (1001 m–5000 m), C (5001 m–7500 m), D (7501 m-10,000 m), and Outer (> 10,000 m) zones defined as the distance from the centroid of the postcode to hospital. Percentages in the “All presentations” columns refer to total presentations in the respective column. Percentages in the “Patients with COVID-19” columns refer to the proportion of all attendances that became COVID-19 hospitalisations. Percentages in the “Change in presentations” columns refer to the difference in all ED attendances in 2020 compared to historic (2015–2019) data. This figure has been created using R version 4.0.3

Fig. 3

Daily emergency admissions at ICHNT of (a) non-COVID vs COVID-19 patients and (b) change by disease area for the period of March 12 to May 31, 2020 compared to historic (2015–2019) average. In (b), the absolute changes for Charing Cross (blue) and St Mary’s (red) hospitals are shown by arrows, with labels showing percentage changes. The historic data refers to the average of emergency admissions between the period from March 12 and May 31 for each year. (ACS – Acute Coronary Syndrome, ARC – Acute Respiratory Conditions, GU – Genito-Urinary conditions, MSK – musculoskeletal)