As an infectious disease transmission via respiratory droplet secretions or direct contact with the lesions, COVID-19 has caused a global pandemic in a short period, with a higher mortality rate than seasonal flu.[11–13]At present, isolating viruses from samples and testing for specific genes are the main diagnostic modality of choice. The COVID-19 genome mutations are continuously found in the course of the pandemic, and the transmission and virulence are also constantly changing with the mutations. Mankind is still in the exploratory stage of COVID-19. [14] The COVID-19 outbreak is severely affecting the health services system worldwide. [15, 16] COVID-19 is accompanied by a variety of symptoms, 80% of infected patients even have no symptoms or mild symptoms. [17] Therefore, it is necessary for ED which is the frontline of hospitals to distinguish suspected infection patients more carefully. [18]In the current COVID-19 situation, strict screening and careful admission are necessary. Therefore, all patients in the ED were subjected to epidemiological investigation and nucleic acid tests, and were subjected to isolation and protection. In the actual work process, it was found that for non-critical patients in ED, before the test results of in-room patients were confirmed in the ED, our next triage seemed to be limited, which may reduce the bed turnover rate in the ED.
This study found that LOS in the ED during the COVID-19 group was longer than the pre-COVID-19 group. Six hours is generally considered a reasonable level of ED stay. [19]The reasons for crowding in the ED can be divided into three aspects: input, throughput and output. For this study, there was no significant difference in the overall number of patients between pre-COVID-19 group and COVID-19 group. The crowding caused by the prolonged length of stay in the ED was mainly considered from two aspects: throughput and output. Several studies[20, 21] have shown that waiting for hospitalization in ED is one of the main reasons for crowding and detention in ED. Fatovich et al. [22] considered that the root cause of ED overcrowding and retention lies in whether the hospital can provide enough inpatient beds.
During the COVID-19, the hospitalization patients, SARS-Cov-2 nucleic acid tests, chest computerized tomography (CT) and other related examinations are needed to determine the next step, and the results of relevant examinations for patients in the ED cannot be obtained quickly, resulting in a certain delay in the evaluation and treatment of patients. During the outbreak of the COVID-19, some emergency medical staff respond to the call and arrived in the severely affected areas for assistance, which to a certain extent caused the shortage of ED staff and delayed the triage of patients.
Emergency internal medical patients usually have more complex conditions and have more complications. So, it takes more time for subspecialties to coordinate, and patients are likely to stay in the ED for a long time. During the course of admitting patients to specialties during the COVID-19 pandemic, subspecialities tend to put their emphasis on assessing patient epidemiological factors to prevent the spread of the epidemic, which makes it more difficult for patients to leave ED. In addition, during the COVID-19 pandemic, the workload of laboratory staff has increased to some extent, which directly affects the production speed of laboratory results. And the patient's condition evaluation not only depends on the symptoms but often also needs to combine the results of laboratory tests and radiographic data. Hospitalization or discharge should be decided after comprehensive consideration. The delay of laboratory results may reduce the bed turnover rate to a certain extent. [23]Trauma patients were the main reason for entering emergency surgery, and car accidents were one of the main reasons. Other surgical patients include patients with abdominal pain such as intestinal obstruction and appendicitis, and patients with aortic dissection, Etc. For surgical patients in urgent need of emergency surgery, the treatment in ED was mainly symptomatic treatment and maintaining vital signs, and emergency surgical treatment was the main part of the treatment. Such patients can still have access to the green channel during the COVID-19 pandemic. Instead of waiting for SARS-CoV-2 nucleic acid results, they can be treated with surgery in a timely way after a CT scan and rapid assessment by a COVID-19 assessment panel. Patients who were not undergoing emergency surgery during the COVID-19 pandemic had to wait in ED for SARS-CoV-2 nucleic acid results to be negative before they could be admitted to hospital. These patients could have been hospitalized only if a bed was available in the specialist ward. This may be an important reason for the prolonged LOS of emergency surgical patients in the ED.
Most of the patients first diagnosed in the emergency neurology department were cerebral infarction or spontaneous intracerebral hemorrhage (ICH). Patients with severe intracerebral hemorrhage with surgical indications should be treated according to emergency surgical procedures. According to the recommended treatment strategies,[24–26] in addition to recombinant tissue plasminogen activator (rt-PA), there are few effective treatments for ischemic stroke, but the therapeutic window of rT-PA is 4.5 hours, beyond which the risk of cerebral hemorrhage is significantly increased. So, emergency thrombolysis for eligible patients with cerebral infarction and symptomatic treatment for concurrent symptoms such as high fever, hyperglycemia, and dysphagia are generally completed in the stroke unit of the ED. After the end of emergency treatment, patients will be transferred to observation or hospitalization. In this process, it is enough to wait for the SARS-CoV-2 nucleic acid results of patients. This process of diagnosis and treatment may be the reason why the LOS of patients in the emergency neurology department was not prolonged during the COVID-19 pandemic period.
Several studies revealed that[27–30] mortality increased is a common adverse consequence of ED crowding. However, this study shows that although the LOS of patients is longer in the ED during the COVID-19 pandemic period, the overall mortality rate does not change significantly. Generally, high mortality in the emergency room mainly includes acute heart disease, critically ill patients who need to be admitted to the Intensive Care Unit for monitoring and treatment, or patients who need emergency surgery. During the COVID-19 pandemic period, the hospital maintained the policy of emergency surgery and critically ill patients first and opened a green channel for critically ill patients. For example, critically ill patients with a low risk of COVID-19 infection should be admitted to subspecialized isolation wards for positive treatment, and be released when the results are negative. Patients requiring emergency surgery were reported to the medical office for surgical treatment and then isolated to a single ward for inspection results. Perhaps, the mortality is not increased during the COVID-19 pandemic period in ED due to the effective implementation of these measures.
Although the study suggested that the LOS in the ED had no significant adverse effect on mortality the overcrowded ED caused by the prolonged LOS in the ED still led to other adverse consequences, such as patients' unsatisfactory medical treatment, patients' privacy exposure, excessive work pressure of staff, medical disputes, Etc. The prolonged LOS in ED during the COVID-19 should be taken seriously. And staff, ED, hospitals and policymakers should work together to establish more effective triage mechanisms, such as increasing ED staff, improving ED rapid testing equipments, and increasing the number of isolation wards in each department in response to triage patients in ED during the COVID-19.