Impact of COVID-19 Pandemic on Emergency Department Volume and Acuity in Low Incidence Area: Taiwan’s Experience in Three Hospitals

Abstract

Background

The decrease in emergency department (ED) patient visits during the COVID-19 pandemic was reported by various studies. Our study aimed to investigate whether a similar trend can be observed in a country with a low incidence of COVID-19 as well as the impact caused by the pandemic on ED patients in different triage levels and categories.

Methods

This multicenter retrospective study collected data from three regional hospitals between March 2019 and December 2020. We evaluated the differences between patient volume, disease severity, and patient composition in ED before and after the COVID-19 pandemic among these hospitals.

Results

There was a 23% reduction in ED patient volume in the urban hospital (hospital A) as well as a 16% reduction in suburban hospitals (hospitals B and C) during the pandemic period, respectively. The regression analysis showed a high correlation in the change in monthly patient volume among these hospitals. In terms of severity, there was a 24% reduction in ED visits with high severity levels (Taiwan Triage and Acuity Scale [TTAS] I, II) in hospital A, as well as 16% and 12% in hospitals B and C during the pandemic period, respectively. Similarly, there was a 23% reduction in ED visits with low severity levels (TTAS III, IV, V) in hospital A, as well as 20% and 16% in hospitals B and C during the pandemic period, respectively. In terms of patient types, there was a significant decline in non-traumatic adult patients (19%, 17%, and 10%), and pediatric patients (49%, 50%, and 46%) in hospitals A, B, and C, respectively.

Conclusions

Despite the low incidence of COVID-19 in Taiwan, a decrease in total ED visits was still found during the pandemic, especially in non-trauma adult visits and pediatric visits. In addition, ED visits in both high and low severity levels decreased in these regional hospitals.

Introduction

Since the first case infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was reported in Wuhan, China in December, 2019, 1 - 4 and the coronavirus disease 2019 (COVID-19) pandemic was declared by the World Health Organization (WHO) in March, 2020, 5 relevant governmental response actions, including quarantines, stay-at-home orders, and city lockdowns, have been taken to prevent further viral transmission. These governmental policies along with the public fear of SARS-CoV-2 infection have affected individuals’ will to visit a hospital, which in turn caused a major impact on healthcare systems worldwide. 6 Meanwhile, various alternative methods, such as telemedicine, remote monitoring, video conference, or phone tracking, have been developed rapidly to replace traditional hospital visits. 7 , 8 As a result, several studies from various countries have demonstrated obvious reductions in the emergency department (ED) patient volumes during the COVID-19 pandemic. 9 - 15

Although published literature has reported the change in ED patient volumes and found a significant difference in the composition of ED visits (i.e., non-trauma adult, trauma, or pediatrics) and disease severity (i.e., triage levels I–V) before and after the COVID-19 pandemic, 9 - 15 most of the studies were conducted in the early period of COVID-19 pandemic between January and May in 2020, and in areas with a high incidence of COVID-19. 9 - 13 Our study aimed to investigate whether a similar trend and characteristics of reduction in ED patient visits could be observed in Taiwan, where did not have a new local case of COVID-19 diagnosed after April 12 during the study period.

Methods

Study Design and Patient Population

This multicenter retrospective study was conducted using the data collected from the administrative boards of EDs in three regional hospitals in southern Taiwan that has a capacity of around 800 to 1,365 beds and 40,000 to 80,000 emergency visits per year. Ditmanson Medical Foundation Chia-Yi Christian Hospital, located in an urban area, was represented by hospital A. Dalin Tzu Chi Hospital and E-DA Hospital, both located in suburban areas, were represented by hospitals B and C, respectively. Data were obtained through the administrative boards as part of the institutional operations and quality improvement. Ethics approval for this study was granted by the Institutional Review Board of the E-DA Hospital (EMRP-110-078). The need for informed consents was waived because of the retrospective nature of the present study.

The data were collected from March 2019 to December 2020. The start of COVID-19 pandemic was defined as the announcement made by WHO in March 2020. We compared the differences between the ED visits in COVID-19 pandemic from March to December in 2020 and the corresponding pre-pandemic period from March to December in 2019. We evaluated the differences in terms of total ED patient volume, triage levels, and composition of ED visits before and after COVID-19 pandemic among these hospitals.

Study Parameter and Definition

The EDs in these three hospitals all comprised non-trauma adult unit, trauma unit, and non-trauma pediatric unit. A patient over 18 years of age was defined as an adult. Obstetric and gynecologic ED visits were excluded because of the small patient volume. Taiwan Triage and Acuity Scale (TTAS), which was a five-level scale used for disease urgency assessment in the present study, is a modification of the Canadian Triage and Acuity Scale. Apart from the chief complaints, TTAS also takes vital signs, level of consciousness, pain severity, and the mechanism of trauma into account. There are five levels of urgency: level I, resuscitation; level II, emergency; level III, urgent; level IV, less urgent; and level V, non-urgent. 16

Statistical Analysis

All data were analyzed by using SPSS version 22 (SPSS Inc, Chicago, IL). Student’s t -test was used for determining the significance of difference among continuous variables. A two-tailed p value of less than 0.05 was considered statistically significant. Furthermore, the trends of total ED patient volume in these three hospitals were analyzed by using Pearson’s correlation coefficient, ranging from –1 to 1, to assess the correlation between each paired group.

Results

The change of monthly ED volumes from March to December in 2020 was demonstrated ( Fig. 1 ). The trend of change in ED patient volume started from March and lasted till September, followed by a slight return to a level more similar to 2019 after October 2020 in all three hospitals ( Fig. 1 ). There was a 23% decrease in total ED volume in the urban hospital (hospital A), as well as 16% decreases in both suburban hospitals (hospitals B and C) during COVID-19 pandemic, and all of which reached statistical significance ( p value < 0.001) ( Table 1 ). In addition, the trend of monthly ED volume during COVID-19 pandemic showed a high correlation (R from 0.805 to 0.949) among the three hospitals ( Fig. 2 ).

Fig. 1 . Variabilities of monthly emergency department patient volumes before and after COVID-19 pandemic in three hospitals.

^* p value < 0.05.

Table 1 . Comparison of total ED volumes before and after COVID-19 pandemic .

^a Pre-pandemic period defined from March to December in 2019.

Group	Pre-pandemic ED visitsa	Pandemic ED visitsb	Decreased rate (%)	p value
Hospital A	76,890	59,162	23	< 0.001 *
Hospital B	35,141	29,393	16	< 0.001 *
Hospital C	51,879	43,706	16	< 0.001 *

Fig. 2 . Comparing the trend of monthly emergency department patient volumes during the period of COVID-19 pandemic and the associated correlation between three hospitals.

^* p value < 0.05.

A significant decrease in ED patient volume during the COVID-19 pandemic was observed across all triage levels in the three hospitals ( Table 2 ). In high disease severity (triage levels I and II), significant decreases in patient volume were observed in hospitals A, B, and C (24%, 16%, and 12%, respectively). Likewise, significant decreases in patient volume of low disease severity (triage levels III–V) were also observed in hospitals A, B, and C (23%, 20%, and 16%, respectively). Additionally, ED visits of low disease severity reduced more than those of high disease severity in suburban hospitals during COVID-19 pandemic (20% vs. 16% in hospital B and 16% vs. 12% in hospital C).

Table 2 . Comparison of patient volumes with different triage level before and after COVID-19 epidemic .

^a Pre-pandemic period defined from March to December in 2019.

Group	High triage level (I, II)					Low triage level (III, IV, V)
	Pre-pandemic ED visits a (%)	Pandemic ED visits b (%)	Decreased rate (%)	p value		Pre-pandemic ED visits (%)	Pandemic ED visits (%)	Decreased rate (%)	p value
Hospital A	14,598 (19.0)	11,040 (18.7)	24	< 0.001 *		62,295 (81.0)	48,111 (81.3)	23	< 0.001 *
Hospital B	6,987 (19.9)	5,897 (20.7)	16	< 0.001 *		28,153 (80.1)	22,596 (79.3)	20	< 0.001 *
Hospital C	7,652 (14.7)	6,772 (15.5)	12	< 0.001 *		44,227 (85.3)	36,934 (84.5)	16	< 0.001 *

As for composition of ED patients, the ED pediatric visits during the COVID-19 pandemic had dramatically decreased in hospitals A, B, and C (49%, 50%, and 46%, respectively, all p value < 0.001) ( Table 3 ). Similarly, in terms of non-trauma adult visits, significant decreases in ED patient visits were also observed in all hospitals (19%, 17%, and 10%, respectively, all p value < 0.001). Nevertheless, the rates of decreases for trauma visits in the three hospitals were 6%, 7%, and 6% during COVID-19 pandemic, respectively, which had no statistical significance ( p value = 0.18, 0.054, and 0.073, respectively).

Table 3 . Comparison of patient volumes among different composition of ED visits before and after COVID-19 pandemic .

^a Pre-pandemic period defined from March to December in 2019.

Group	Adult, non-trauma					Trauma
	Pre-pandemic ED visitsa	Pandemic ED visitsb	Decreased rate (%)	p value		Pre-pandemic ED visits	Pandemic ED visits	Decreased rate (%)	p value
Hospital A	45,930	37,127	19	< 0.001 *		13,961	13,119	6	0.180
Hospital B	25,260	21,081	17	< 0.001 *		6,310	5,892	7	0.054
Hospital C	30,338	27,194	10	0.001 *		12,020	11,318	6	0.073

Discussion

In the present study, our findings are consistent with other studies conducted in countries with high incidence of COVID-19, 9 - 13 revealing that despite the low incidence of COVID-19, there has been a similar pattern of decrease in volume either in total ED visits or in specific types of ED visits in Taiwan. A previous study in northern Taiwan has shown that there was a 33.45% decrease in ED visits during the pandemic, which was more significant than our report (16%–23%), but the study only collected data in one northern medical center, and it was investigated in the very early phase of COVID-19 pandemic as well as only between the short period of February and April in 2020. 15 In current study, we enrolled three different regional hospitals as well as a more extended study period, disclosing that the impact of COVID-19 pandemic on ED visits has sustained until September 2020, and it was not until after October 2020 that the ED volumes eventually returned closer to the usual of 2019. Our study also demonstrated that the correlational trend of changes in ED volumes occurred among all enrolled hospitals. Even though there was no new local case of COVID-19 diagnosed after April 12 in Taiwan, the trend of decline in ED volumes persisted until October 2020. This phenomenon indicated that the concern for SARS-CoV-2 infection, which consequently resulted in the avoidance of ED visits, might not have only been affected by the local spread of COVID-19, but also by the global pandemic. 15 Furthermore, the corresponding containment measures to COVID-19 pandemic by the Taiwanese Ministry of Health and Welfare during this period also contributed to the decline of ED volume. 14

This is the first study to assess the impact on ED visits in different regional hospitals during COVID-19 pandemic. There was a disproportional decrease in the hospital located in an urban area (23% decrease in hospital A) compared with those two in suburban areas (both 16% decreases). Around 79%–85% of ED visits were composed of low triage levels (levels III–V) ( Table 2 ). Therefore, the decreased ED visits of low triage levels might contribute majorly to the total ED volumes. A national retrospective study in Taiwan demonstrated patients living in urbanized areas had a higher propensity for non-emergent ED visits. 17 Thus, the concern for COVID-19 might drastically reduce the non-emergent ED visits during COVID-19 pandemic 6 , 9 and cause the disproportional decrease in ED patients in hospitals located in urban areas. Indeed, hospital A had a higher rate of decrease than hospitals B and C (23% vs. 20% and 16%, respectively) in low triage levels.

In addition to ED patient volume, the disease severity of ED visits was another issue related to ED overcrowding and resource utilization. 18 Although the alternative behavior in seeking health care during COVID-19 pandemic because of the fear of getting infected by a novel virus could be predicted, 6 , 9 ED patients with high severity disease was not expected to decrease because of the high requirement for ED medical resources in this group. However, the phenomenon was not observed in the present study. Regardless of disease severity, decreases in ED patient volume in both high and low triage levels were observed. The rates of decrease in ED visits of high triage levels demonstrated 24%, 16%, and 12% in hospitals A, B, and C, respectively. We deduced a few possible explanations for the decline of ED visits in high triage levels. First, emergency medical service administrators might prefer transferring critical patients to medical centers rather than regional hospitals because of the fact that more medical capacity and resources are available in the former option. 12 Indeed, studies in two medical centers in Taiwan also revealed no significant decrease in critical patients in ED visits. 15 , 19 Second, wearing masks, handwashing, and social distancing could contribute to reduced incidence of some infectious diseases, such as influenza and enterovirus infection, or all-cause of pneumonia, which might reduce ED visits of both high and low disease severity. 20 Third, the assessment of triage levels according to triage and acuity scale could not fully represent the severity and complexity of patients’ diseases. 18 , 21

In terms of composition of ED visits, all hospitals uniformly showed significant declines in non-trauma adult patients and pediatric patients. Interestingly, the pediatric ED visits showed a greatly disproportional decline around 50% in all three hospitals, which was also observed in other studies. 9 , 11 , 15 The public health policies for COVID-19 may have inadvertently prevented the spread of various infectious diseases, such as enterovirus infection or respiratory disease, in pediatric and adult patients. 11 , 20 Conversely, trauma cases in the ED showed no obvious decrease during the COVID-19 pandemic. An observational study in Italy demonstrated decline in trauma ED visits during the COVID-19 pandemic because of restrictions on outdoor activities, such as curfews, which might in turn reduce injury-related visits to ED. 11 However, the significant decrease in trauma ED visits was not observed in our study partly owing to the fact that containment measures were not performed in Taiwan because of our low incidence of COVID-19.

During the pandemic, the arrangement of manpower in ED was crucial. Apart from regular medical tasks, multiple measures have been adopted for pandemic management and prevention in ED. Medical facilities were impacted by the pandemic, and resource management became challenging. Our study described a trend in the change of ED volume during the pandemic which can provide additional information for the rearrangement of emergency medical personnel and resources during pandemic. For instance, the sharp decline in adult and pediatric non-trauma visits may allow more emergency physician or pediatrician to work on pandemic prevention such as screening test for a possible novel virus in the future.

There are several limitations in this study. Firstly, we did not conduct detailed analysis of the specific diseases for ED patients, and the triage levels could not completely represent the disease severity. Secondly, the study was conducted at regional hospitals in Taiwan which may restrict the generalizability of our findings. Thirdly, the data were collected from March to the end of 2020, and hence the changing pattern of ED volumes could be different so long as the COVID-19 pandemic persisted. In conclusion, despite low incidence of COVID-19 in Taiwan, total ED visits still significantly dropped during the COVID-19 pandemic, and all regional hospitals enrolled in the study had a high correlation in the trend of monthly volume changes. Obvious decreases in non-trauma adult and pediatric ED visits were observed, but not in trauma visits. In addition, ED visits all decreased regardless of the disease severity level.

Conflicts of Interest Statement

There are no conflicts of interest

Acknowledgments

The authors would like to thank Ditmanson Medical Foundation Chia-Yi Christian Hospital and Dalin Tzu Chi Hospital which contributed data during the COVID-19 pandemic in 2020 to this study.