Emergency Department Volume Research Articles

Characteristics of Emergency Department Visits Made by Individuals With Sickle Cell Disease in the U.S., 1999–2020

Individuals living with sickle cell disease experience high levels of morbidity that result in frequent utilization of the emergency department. The objective of this study was to provide updated national estimates of emergency department utilization associated with sickle cell disease in the U.S. Data from the National Hospital Ambulatory Medical Care Survey for the years 1999-2020 were analyzed. Complex survey analysis was utilized to produce national estimates overall and by patient age groups. On average, approximately 222,612 emergency department visits occurred annually among individuals with sickle cell disease, a nearly 13% increase from prior estimates. The annual volume of emergency department visits steadily increased over time, and pain remains the most common patient-cited reason for visiting the emergency department. Patient-reported pain levels for individuals with sickle cell disease were high, with 64% of visits associated with severe pain and 21% associated with moderate pain. Public insurance sources continue to cover most visits, with Medicaid paying for 60% of visits and Medicare paying for 12% of visits. The average time spent in the emergency department increased from previous estimates by about an hour, rising to approximately 6 hours. The average wait time to see a provider was 53 minutes. Utilization of the emergency department by individuals living with sickle cell disease remains high, especially for pain. With more than half of patients with sickle cell disease reporting severe pain levels, emergency department staff should be prepared to assess and treat sickle cell disease-related pain following evidence-based guidelines and recommendations. The findings of this study can help improve care in this population.

Database derived from an electronic medical record-based surveillance network of US emergency department patients with acute respiratory illness

BackgroundFor surveillance of episodic illness, the emergency department (ED) represents one of the largest interfaces for generalizable data about segments of the US public experiencing a need for unscheduled care. This protocol manuscript describes the development and operation of a national network linking symptom, clinical, laboratory and disposition data that provides a public database dedicated to the surveillance of acute respiratory infections (ARIs) in EDs.MethodsThe Respiratory Virus Laboratory Emergency Department Network Surveillance (RESP-LENS) network includes 26 academic investigators, from 24 sites, with 91 hospitals, and the Centers for Disease Control and Prevention (CDC) to survey viral infections. All data originate from electronic medical records (EMRs) accessed by structured query language (SQL) coding. Each Tuesday, data are imported into the standard data form for ARI visits that occurred the prior week (termed the index file); outcomes at 30 days and ED volume are also recorded. Up to 325 data fields can be populated for each case. Data are transferred from sites into an encrypted Google Cloud Platform, then programmatically checked for compliance, parsed, and aggregated into a central database housed on a second cloud platform prior to transfer to CDC.ResultsAs of August, 2023, the network has reported data on over 870,000 ARI cases selected from approximately 5.2 million ED encounters. Post-contracting challenges to network execution have included local shifts in testing policies and platforms, delays in ICD-10 coding to detect ARI cases, and site-level personnel turnover. The network is addressing these challenges and is poised to begin streaming weekly data for dissemination.ConclusionsThe RESP-LENS network provides a weekly updated database that is a public health resource to survey the epidemiology, viral causes, and outcomes of ED patients with acute respiratory infections.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BackgroundThe end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. ObjectiveThis study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. MethodsThe study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. ResultsThe study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1–46.3%; p < 0.001) and 22.1% (95% CI 19.3–26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1–3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. ConclusionsTotal adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Changes in emergency department use in British Columbia, Canada, during the first 3 years of the COVID-19 pandemic.

Previous studies have shown reductions in the volume of emergency department visits early in the COVID-19 pandemic, but few have evaluated the pandemic's impact over time or stratified analyses by reason for visits. We aimed to quantify such changes in British Columbia, Canada, cumulatively and during prominent nadirs, and by reason for visit, age and acuity. We included data from the National Ambulatory Care Reporting System for 30 emergency departments across BC from January 2016 to December 2022. We fitted generalized additive models, accounting for seasonal and annual trends, to the monthly number of visits to estimate changes throughout the pandemic, compared with the expected number of visits in the absence of the pandemic. We determined absolute and relative differences at various times during the study period, and cumulatively since the start of the pandemic until the overall volume of emergency department visits returned to expected levels. Over the first 16 months of the pandemic, the volume of emergency department visits was reduced by about 322 300 visits, or 15% (95% confidence interval 12%-18%), compared with the expected volume. A sharp drop in pediatric visits accounted for nearly one-third of the reduction. The timing of the return to baseline volume of visits differed by subgroup. The largest and most sustained decreases were in respiratory-related emergency department visits, visits among children, visits among oldest adults and non-urgent visits. Later in the pandemic, we observed increased volumes of highest-urgency visits, visits among children and visits related to ear, nose and throat. We have extended evidence that the impact of the COVID-19 pandemic and associated mitigation strategies on emergency department visits in Canada was substantial. Both our findings and methods are relevant in public health surveillance and capacity planning for emergency departments in pandemic and nonpandemic times.

Boarding in US Academic Emergency Departments During the COVID-19 Pandemic.

The first 2 years of the COVID-19 pandemic brought substantial and dynamic changes to emergency department volumes and throughput. The objective of this study was to describe changes in ED boarding among US academic EDs across the duration of the COVID-19 pandemic. We conducted a retrospective analysis of monthly data collected from a convenience sample of academic departments of emergency medicine. The study period was from January 2019 to December 2021. The primary outcome was total boarding hours, and secondary outcomes included patient volume stratified by ED disposition. We used multivariable linear panel regression models with fixed effects for individual EDs to estimate adjusted means for 3-month quarters. Of the 73 academic departments of emergency medicine contacted, 34 (46.6%) participated, comprising 43 individual EDs in 25 states. The adjusted mean total boarding hours per month significantly decreased during the second quarter of 2020 (4,449 hours; 95% confidence interval [CI] 3,189 to 5,710) compared to the first quarter of 2019 (8,521 hours; 95% CI 7,845 to 9,197). Beginning in the second quarter of 2021, total boarding hours significantly increased beyond pre-pandemic levels, peaking during the fourth quarter of 2021 (12,127 hours; 95% CI 10,925 to 13,328). A sustained and considerable increase in boarding observed in selected US academic EDs during later phases of the COVID-19 pandemic may reflect ongoing stresses to the health care system, with potential consequences for patient outcomes as well as clinician well-being.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022. We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states. Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day. ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Emergency Department Volume Numbers Don’t Tell the Whole Story: The Rising Toll of Boarding and High-Acuity Care

Emergency Department Volume Numbers Don’t Tell the Whole Story: The Rising Toll of Boarding and High-Acuity Care

Effect of the coronavirus disease 2019 pandemic on pediatric emergency department visits for acute gastroenteritis evaluated using a validated clinical severity score.

The coronavirus disease 2019 (COVID-19) outbreak that began in late 2019 has significantly affected quality of life and healthcare. Approaches to prevent the spread of COVID-19 have also affected the prevalence of other diseases. This retrospective review evaluated pediatric emergency department (PED) volume, in terms of children with acute gastroenteritis (AGE), and changes in AGE severity before versus during the COVID-19 pandemic in a tertiary medical center in Taiwan. Patients who visited the PED and were diagnosed with AGE during the 70-day COVID-19 lockdown in 2021, or the identical period in 2020, were compared using a clinically validated AGE severity score, the modified Vesikari score (MVS), and additional parameters. During the COVID-19 outbreak, there was a 61.4% reduction in the number of children with AGE visiting the PED. In that period, the AGE severity score was similar compared to the pre-pandemic period (9.00 vs. 8.57, p=0.273). The mean C-reactive protein (CRP) level (55.7 vs. 40.6mg/L, p<0.001) and rate of antibiotics use (48% vs. 23.5%, p<0.001) were higher during the outbreak than the pre-pandemic period. The number of children with AGE visiting the PED decreased during the COVID-19 outbreak, while disease severity was unchanged compared to the pre-pandemic period. The use of antibiotics during the COVID-19 pandemic warrants further investigation.

Emergency Department Volume and Delayed Diagnosis of Pediatric Appendicitis: A Retrospective Cohort Study.

To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis. Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness. Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence. Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54). Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications.

Difference in impact on emergency department visits following four major peaks of COVID-19 cases

Objective: Several variants of SARS-CoV-2 have emerged since its first appearance in 2019, greatly impacting healthcare systems across the globe. Previous literature indicated a substantial decline in emergency department (ED) visits in hospitals since the start of the COVID-19 pandemic. However, little research has been done to compare different variants’ (Ancestral, Alpha, Delta, Omicron, etc.) impact on patients presenting to the ED. Thus, the purpose of this retrospective observational study is to compare the changes in total ED volume following four major peaks of SARS-CoV-2 infection within a multi-hospital health system.Methods: Utilizing electronic healthcare record (EHR) data, total ED visits (484,268) and COVID-19 case counts (24,358) were collected and analyzed to compare ED census and COVID-19 trends across four years and four variant peak periods, from January 2019 to June 2022.Results: Results showed that ED visits declined after the first two major peaks (Ancestral and Alpha) in COVID-19 cases, which was consistent with national trends and prevailing literature. In contrast, ED visits increased following the fourth major peak (Omicron) in COVID-19 cases.Conclusions: The increase in ED visits following the fourth major peak was inconsistent with previous literature and trends. This may be attributed to the severity differences between variants, increased vaccination uptake, newly adopted public countermeasures, and evolving perceptions of safety and fear regarding COVID-19. These results underscore the critical importance for health administrators and policy planners to be cognizant of new strategies that alleviate barriers to receiving emergency care, especially during times of crisis.

Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline

BackgroundLeft without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended. ObjectiveWe assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS. MethodsWe performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018–February 2020), during early COVID-19 (COVID, March 2020–June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021–December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively. ResultsMean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am. ConclusionsLWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.

The Incidence and Risk Factors for Emergency Department Imaging in Acute Renal Colic.

Objective: To determine the incidence of and risk factors for imaging in patients presenting to the emergency department (ED) with renal colic. Subject/Patients and Methods: We conducted a population-based cohort study in the province of Ontario, utilizing linked administrative health data. Patients who presented to an ED with renal colic between April 1, 2010, and June 30, 2020, were included. The rate of initial imaging (CT scans and ultrasound [U/S]) and repeat imaging within 30 days was determined. Generalized linear models were utilized to evaluate patient and institutional-level characteristics associated with imaging, and specifically CT vs U/S. Results: There were 397,491 index renal colic events, of which 67% underwent imaging (CT 68%, U/S 27%, and CT+U/S same day 5%). Repeat imaging was performed in 21% of events (U/S in 12.5%, CT in 8.4%) at a median of 10 days. Of those with an initial U/S, 28% had repeat imaging compared with 18.5% for those with an initial CT. Undergoing an initial CT was associated with being male, urban residence, later year of cohort entry, history of diabetes mellitus and inflammatory bowel disease, and presentation to nonacademic hospitals of larger size, or with a higher volume of ED visits. Conclusion: Two-thirds of renal colic patients underwent imaging, and CT was the most utilized modality. Patients undergoing an initial CT had a lower likelihood of repeat imaging within 30 days. The utilization of CT increased over time and was more common in males and those presenting to nonacademic hospitals of larger size, or with higher ED volumes. Our study highlights the patient- and institution-level factors that need to be targeted with prevention strategies to reduce the utilization of CT scans, when possible, for cost reduction and to minimize patient exposure to ionizing radiation.

Epidemiologic Burden and Projections for Eosinophilic Esophagitis–Associated Emergency Department Visits in the United States: 2009-2030

Patients with poorly controlled eosinophilic esophagitis (EoE) may require unplanned emergency department (ED) visits for the management of dysphagia or food impactions. We evaluated the epidemiologic burden of EoE on ED utilization in the United States. Data from the US Nationwide Emergency Department Sample were used to estimate weighted annual EoE-associated ED visits from 2009-2019. Temporal trends in population-adjusted rates of EoE visits were assessed using joinpoint regression. Autoregressive integrated moving average models were used to project EoE-associated ED visits to 2030. We also evaluated endoscopic utilization, requirement for hospitalization, and ED-related charges in patients with EoE presenting to ED. A total of 11,125 unweighted (49,507 weighted) ED visits for EoE were included (69.0% male, mean age 32.4 years). The annual volume of EoE-associated ED visits increased from 2,934 [95% CI: 2,437-3,431] in 2009 to 8,765 [95% CI: 7,514-10,015] in 2019 and is projected to reach 15,445 [95% prediction interval PI: 14,672-16,218] by 2030. From 2009 to 2019, the number of EoE-associated ED visits increased by an average of 11.5%/year [95% CI: 10.3%, 12.7%]. The proportion of patients admitted to hospital from ED decreased from 25.6% in 2009-2011 to 14.0% in 2017-2019. Half of EoE patients presenting to ED required endoscopy, and nearly 40% required esophageal foreign body removal. Total mean inflation-adjusted charges for an EoE-associated ED visit were $9,025 US dollars in 2019. The volume of EoE-associated ED visits tripled between 2009 to 2019 and is projected to further double by 2030. This represents a substantial burden of unanticipated healthcare resource utilization and highlights a potential opportunity to optimize outpatient EoE care.

Assessing Trends and Severity of Emergency Department Access Block by Measuring Median ED Length of Stay for Admitted Patients

Introduction:The Emergency Department (ED) is the hospital’s main gateway, as well as the initial site for diagnosis and emergency medical care. In recent years, ED overcrowding is worsening in Israel and world-wide. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction, as well as lowering quality of care and even increasing mortality. A main driver of ED overcrowding is ED patient boarding due to limited inpatient bed availability in conjunction with hospital policy. Measuring median length of ED stay (LOS) for admitted vs. discharged patients can serve as a simple indicator for the severity of the access block over time and between facilities.Method:ED operational data from the computerized system of four hospitals in Israel were collected over a year and analyzed. In parallel data was collected regarding hospital capacity and ED volumes. Data were analyzed using SPSS.Results:The Mean ED LOS was significantly higher for ED patients needing admission in all hospitals. Mean ED LOS for admitted vs. discharged patients was 227 min vs.431 in hospital A, 215 min vs. 222 in hospital B, 198 min vs. 440 in hospital C and 167 min vs. 190 in hospital D. The discrepancy in LOS for admitted patients was not related to the total hospital bed capacity or the hospital ED patient volume.Conclusion:ED boarding is a major challenge for ED's and hospitals worldwide and a significant contributor to ED overcrowding. A tool to assess boarding is proposed. The tool calculates the ratio of median ED LOS between patients admitted to the hospital and those discharged. Slightly higher LOS among those admitted is to be expected, considering the fact that they usually present with more complex medical problems. In this study the LOS ratios were 1.03, 1.12, 1.90 and 2.22.

Pediatric Disaster Readiness and Community Hospitals in a Rural American State

Introduction:Pediatric patients represent a small (but important) subset of the patient population routinely visiting emergency departments (ED) each year. With the aim of better understanding the disaster preparedness level for pediatric-specific mass casualty and surge incidents, a survey was conducted involving all hospitals that routinely manage pediatric patients in their emergency departments, to better understand the preparedness levels for these facilities.Method:This is a retrospective analysis of data collected in 2014 and repeated in 2021. Our focus included one predominantly rural state in the United States of America (USA). We examined results from surveys conducted where facilities self-reported objective criteria that resulted in a readiness score (as it relates to pediatric readiness). Reporting stratification reflected the annual pediatric ED volume with groups of; Low (&lt;1800/year), Medium (1800-4999 /year), Medium to High (5000-9999/year), and High (&gt;10,000/year).Results:Low-volume hospitals scored (Mean=59/Median=56), Medium volume hospitals scored (Mean=62/Median=60), Medium to High volume hospitals (Mean=67/Median=65), and hospitals with High volumes (Mean=82/Median=83). All hospital volume ranges had outlier hospitals that scored between 82-97. The general tendency, lower volume hospitals had a lower level of readiness, and higher volume hospitals had a higher (to much higher) level of readiness.Conclusion:Pediatric disaster readiness needs to be improved at the community level. It is encouraging that pediatric disaster readiness has been addressed in the larger medical centers. Yet, it should be noted that even very low-volume hospitals (had outliers with) scores as high as 94 indicating that with ample support, and resources, pediatric disaster preparedness is achievable in every hospital regardless of size or volume. The results point to a need to develop, improve, and distribute resources and support local hospitals with pediatric disaster readiness.

Increase in trauma volume as compared to emergency department volume during the COVID-19 pandemic

BackgroundDuring the months between April through June 2020 when we experienced the largest number of COVID-19 patients in our hospital, the volume of patients in the Emergency Department (ED) was decreased by more than 30%. In contrast to most early reports we did not notice a decrease in trauma volume during this time period. Materials and MethodsWe compared trauma patients presenting to our Level III Trauma Center, between April 2019 through June 2019 to those presenting from April 2020 through June 2020, the initial surge in COVID-19 patients. We compared ground level falls (GLF), motor vehicle crashes (MVC), bicycle and skateboard crashes, assault, and other. ResultsThere was a 13% increase in trauma patients presenting during the study period in 2020 as compared to 2019, and the total number of trauma patients as a percentage of total ED patients also increased 269/9235 (2.9%) to 308/6216 (5.0%), P < 0.0001. There was no significant difference in demographics or outcome data between the trauma patients presenting during the two time periods. Although traffic decreased by more than 40%, the number of MVC's was similar. ConclusionThe volume of patients presenting to our Trauma Center as compared to the total ED volume increased during the time period from April through June 2020 versus the year just prior to the COVID-19 pandemic. Despite the fact that the total traffic volume decreased more than 40 percent between these two time periods, the actual number of motor vehicle crashes remained similar.

Trends in Volume and Charges of Retinal Tear Patients in the Emergency Department

ABSTRACT Purpose To characterize retinal tears (RTs) and calculate the economic burden of RTs that present to the emergency department (ED) in the US. Methods We used a large national ED database to retrospectively analyze RTs that presented to the ED from 2006 to 2019. Using extrapolation methods, national of the RT patient ED volume, demographics, comorbidities, disposition, inpatient (IP) charges, and ED charges were calculated. Results During the period between 2006 and 2019, 15841 ED encounters had RT listed as the primary diagnosis. The average annual RT ED encounters was 2,640 ± 856 and comprised an average of 6.4 × 10 − 5 % of all ED visits annually. The number and ED percentage of RT encounters did not change during this time period (p = .22, p = .67, respectively). Most patients were males, Caucasian, paid with private insurance, and admitted to EDs in the Northeast. The most common comorbidities were hypertension (19%), a history of cataracts (15%), and diabetes (7.2%). During this time period, RTs charges added up to more than $79 million and $33 million in the ED and IP settings, respectively. Mean per-encounter ED and IP charges increased by 145% (p = .0008) and 86% (p = .0047), respectively. Conclusion Despite the stable number of RT patients presenting to the ED, RTs place a significant economic burden to the healthcare system, which increases yearly. We recommend physicians and policy makers to work together to pass laws that could prevent the increasing healthcare charges.

Trends in interfacility transfer volume by season, day of week, time of day, and federal holiday status

BackgroundInterfacility transfer patients have poorer outcomes and greater resource needs than the average emergency department (ED) patient, however, trends in transfer rates remain poorly understood. ObjectiveTo quantify temporal trends in the volume of interfacility transfers to the emergency department of an academic referral center. MethodsA retrospective review was performed of all adult patients transferred to the ED of a large, academic medical center in the Northeastern U.S. from 2017 to 2019. The mean transfer and total ED volumes by season, day of week, time of day, and federal holiday status were calculated and compared. ResultsA total of 26,555 adult patients were transferred to the hospital ED from 2017 to 2019. Transfer volume increased by 13% over the study period while total ED volume increased by less than 1%. While transfer patients made up, on average, only 8.6% of ED patients during day shifts, this proportion increased to 16.5% during evening shifts and 18.8% during night shifts. A modest, cyclical weekday pattern was also noted, with the proportion of ED volume from transfers reaching its highest on Saturdays and its lowest on Wednesdays. No consistent trends in transfer volume due to season or holiday status were observed. ConclusionOur center's significant two-year increase in interfacility transfer volume and relative stagnation in total ED volume illustrates an expanding role supporting community facilities. Consequently, transfer patients accounted for an increasing proportion of ED providers' workload during evening shifts and during overnight shifts. Referral centers may benefit from performing similar analyses of their own transfer volume to inform ED resource allocation.

Emergency Department Utilization within a Rural Health System during Early COVID-19 Pandemic

Background: Stay-at-home orders were issued during March 2020 to contain the spread of COVID-19. We sought to understand the impact of COVID-19 on emergency care utilization within one rural health system. Methods: This studied a retrospective cohort of patients presenting to system emergency departments (EDs). Primary outcome was ED volume. Secondary outcomes were admission rate for stroke, acute coronary syndrome (ACS), and critical illness states. A report was generated for all ED visits during study period March 19–May 31, 2020, and reference period: March 19–May 31, 2019. For the primary outcome, a regression model was used. Mixed-effects logistic and linear models were used for evaluating differences in rates for secondary outcomes. Results: There was a decrease in weekly volume (−609 ±57, p &lt; 0.001). There was an increase in admission rate for sepsis (OR 1.43 [95% CI 1.18–1.72]), stroke (OR 1.54 [95% CI 1.11–2.12]), and overall critical illness presentation (OR 1.59 [95% CI 1.41–1.8]). There were higher rates of vasopressor use (OR 1.91 [95% CI 1.56–2.33]) and inpatient mortality (OR 1.49 [95% CI 1.09–2.05]). There were 37 cases of COVID-19. Conclusions: ED volume decreased by 40% with evidence of greater severity of illness in the setting of low COVID-19 disease burden. Efforts should be developed to reassure the public of the importance and safety of timely hospital care during future pandemics. Hospital staffing models should anticipate greater severity of illness despite lower patient volume.

Upper Extremity Musculoskeletal Injuries Presenting to an Emergency Department Before and During the Initial COVID-19 Pandemic Surge.

The SARS-CoV-2 (COVID-19) pandemic significantly impacted emergency department volume and acuity. The Delta and Omicron variants contributed to additional surges. We describe the impact that the initial pandemic phase had on frequency and severity of typically non-life-threatening emergencies using upper extremity injuries as a model for other potentially emergent presentation as compared to pre-pandemic times. We do this using the epidemiology of pre-defined significant upper extremity injuries at our facility as a specific example of what occurred at an urban trauma center. We conducted a comparison of two 6-month periods: between March 2019 and August 2019 (prior to COVID-19) and between March 2020 and August 2020 after the onset of the initial COVID-19 wave. We performed a retrospective chart review of patients who presented with upper extremity injury chief complaints using analysis of the electronic medical record at a single urban tertiary care trauma center in the Midwestern United States. We investigated examination findings, imaging, frequency of surgical procedures and final diagnosis. In the 2019 study period, there were 31,157 ED patients, including 429 with upper extremity injuries, of which 108 patients had significant injuries. In the 2020 study period, there were 24,295 patient presentations, of which 118 of 296 upper extremity presentations were significant. We a priori defined significant injury as follows: fractures, dislocations, neurovascular injuries, or need for operative intervention within 24 hours of ED presentation. Specifically, 25.2% of injuries were significant pre-COVID-19 and 39.9% (p < 0.001) during the initial COVID-19 surge. The absolute number and percentage of significant injuries increased from pre-COVID-19 compared to the initial COVID-19 surge despite an overall 22% decrease in total patient volume. The incidence of significant upper extremity musculoskeletal injuries increased during the pandemic even though the overall number of ED presentations for upper extremity musculoskeletal injuries decreased.