Impact of the COVID-19 pandemic on emergency department attendances and acute medical admissions

Abstract

Background: To better understand the impact of the COVID-19 pandemic on hospital healthcare, we studied activity in the emergency department (ED) and acute medicine department of a major UK hospital.

Methods: Electronic patient records for all adult patients attending ED (n = 243,667) or acute medicine (n = 82,899) during the pandemic (2020-2021) and prior year (2019) were analysed and compared. We studied parameters including severity, primary diagnoses, co-morbidity, admission rate, length of stay, bed occupancy, and mortality, with a focus on non-COVID-19 diseases.

Results: During the first wave of the pandemic, daily ED attendance fell by 37%, medical admissions by 30% and medical bed occupancy by 27%, but all returned to normal within a year. ED attendances and medical admissions fell across all age ranges; the greatest reductions were seen for younger adults in ED attendances, but in older adults for medical admissions. Compared to non-COVID-19 pandemic admissions, COVID-19 admissions were enriched for minority ethnic groups, for dementia, obesity and diabetes, but had lower rates of malignancy. Compared to the pre-pandemic period, non-COVID-19 pandemic admissions had more hypertension, cerebrovascular disease, liver disease, and obesity. There were fewer low severity ED attendances during the pandemic and fewer medical admissions across all severity categories. There were fewer ED attendances with common non-respiratory illnesses including cardiac diagnoses, but no change in cardiac arrests. COVID-19 was the commonest diagnosis amongst medical admissions during the first wave and there were fewer diagnoses of pneumonia, myocardial infarction, heart failure, cellulitis, chronic obstructive pulmonary disease, urinary tract infection and other sepsis, but not stroke. Levels had rebounded by a year later with a trend to higher levels of stroke than before the pandemic. During the pandemic first wave, 7-day mortality was increased for ED attendances, but not for non-COVID-19 medical admissions.

Conclusions: Reduced ED attendances in the first wave of the pandemic suggest opportunities for reducing low severity presentations to ED in the future, but also raise the possibility of harm from delayed or missed care. Reassuringly, recent rises in attendance and admissions indicate that any deterrent effect of the pandemic on attendance is diminishing.

Keywords: Acute medicine; COVID-19; Emergency department; Hospital admissions; Non-COVID-19 disease.

Fig. 1

Daily ED attendance over time with major event time points labelled (WHO=World Health Organization, PHEIC=Public health emergency of international concern, 3 T system = 3-tiered regional lockdown system)

Fig. 2

Impact of the pandemic on ED attendances and medical admissions. (A) Attendances to ED stratified by discharge home within 24 h versus admission for > 24 h. (B) Attendances (non-bed based) and admissions (bed-based) stratified by primary diagnosis of COVID-19. (C) Daily number of medical inpatients stratified by primary diagnosis of COVID-19

Fig. 3

ED attendances (A) and medical admissions (B) stratified into 10 bands of equal age-width (square brackets indicate inclusive, round brackets indicate not inclusive)

Fig. 4

Physiological severity over time based on NEWS2 score risk alert level. (A) Total ED attendances. (B) Medical admissions stratified according to whether a primary diagnosis was COVID-19

Fig. 5

ED attendances by presenting complaint and diagnosis over time. (A) Daily attendances for the 10 commonest presenting complaints (‘Trauma’ includes injury of leg, arm, head injury and pain in the leg). (B) Daily attendances for the 10 commonest primary diagnoses. (C) Daily attendances for the group diagnosis of ‘not applicable’ broken down by subtype

Fig. 6

Daily medical admissions stratified by primary diagnosis for the 10 commonest diagnoses

Fig. 7

Daily medical admissions stratified by primary diagnosis and mortality