As an island country, Taiwan shares borders with no other country. This geographical advantage gives Taiwan an edge in its COVID-19 prevention strategy. In contrast with the worldwide COVID-19 outbreak, Taiwan’s handling of the pandemic crisis was highly lauded by many country as there was no extensive community transmission [10, 18]. Moreover, Taiwan gained experience from facing the SARS outbreak, in 2003.. Taiwan took a series of actions after the SARS outbreak, including governmental reorganization, preparedness for medical care systems, and public engagement [22].
However, in May 2021, Taiwan witnessed its first alarming community spread in the wake of several domestic cases without any known sources of infection, thus, the COVID-19 community transmission began in the country. This outbreak was the largest public healthcare crisis that Taiwan experienced since the start of COVID-19 pandemic. Therefore, understanding the pandemic influence on the ED attendance and utility is important for future health and pandemic planning.
In the first 8 months of 2021, when the community outbreak in Taiwan was the most serious, 43,270 patients visited our ED. This represents an 8.5% reduction compared with the numbers from the previous year and a surprising 25% reduction compared with that in 2019, just a year before the epidemic was declared. While the magnitude of the decline is already impressive, compared to the 37–65% reduction reported in foreign studies, it still trails these numbers by roughly 20 percentage points [11, 19, 23–25]. In 2002, during the peak of the SARS epidemic in Taiwan, the reduction in daily ED visits reached 43.7–51.6% for pre-epidemic numbers, which was similar to the worldwide COVID-19 data [26, 27].
The spread of SARS-associated coronavirus (SARS-CoV) and Middle East respiratory syndrome (MERS) between individuals has been characterized by efficient transmission in healthcare facilities, highlighting the vulnerability of our modern healthcare system to nosocomial infection [28]. Grouping large numbers of ill persons without proper protection can greatly amplify intrahospital transmission [29]. Unlike SARS-COV, SARS-COV-2 exhibits high viral shedding in the upper respiratory tract at the early stage of infection, and a large proportion of transmission-competent individuals are pre-symptomatic, asymptomatic, and mildly symptomatic. These two traits played an important role in and allowed for COVID-19 transmission mostly in the community during the epidemic, which could explain the difference in magnitude of decline between SARS-COV and SARS-COV-2 [28].
In this study, we demonstrated that the COVID-19 epidemic was associated with a significant reduction in ED visits. This effect was observed in traumatic and non-traumatic patients, similar to that of a previous study in Thailand [30]. Despite the decline in ED visits during the peak phase of the epidemic, we observed that the older patients returned to our ED soon after the epidemic slowed, in both traumatic and non-traumatic cases. The number of admissions of older patients after the epidemic was also similar to that before the epidemic, which implies that the older population served the immediate need to seek emergency medical services. Moreover, in our study, the number of patients with triages 1 and 2 who attended the ED remained unchanged during all stages of the COVID-19 epidemic.
The coronavirus pandemic not only had a huge impact on older patients with infection but also affected older adults who did not have infection. Older patients are also at higher risk of functional decline and usually develop medical complications after an ED visit [31]. Access to healthcare and supportive services for chronic conditions is a major concern. Previous investigations revealed that, during the pandemic, older adults were likely to have cancelled or postponed appointments [32]. Chronic respiratory and cardiovascular diseases, which are usually present in the older population, require tight physician–patient cooperation. Inadequate home management of chronic disease during the lockdown period and pandemic period puts the frail older population in a risky situation [33]. Furthermore, social isolation and loneliness, which occurred during the lockdown period, also had a profound impact on older adults’ health [34]. It is a serious and underestimated geriatric health risk that affects both community-dwelling older adults and nursing home residents.
Our study showed that older patients returned to the ED earlier than the general population when the epidemic slowed. This finding highlights the necessity of EDs for the older population. Generally, older persons are characterized by multimorbidity, including hypertension, diabetes mellitus, and malignancy and usually develop medical complications that require ED visits [31]. The delivery of acute care is very important to this vulnerable population, especially during the COVID-19 pandemic. It is easy to realize that people have deferred seeking medical attention for non-COVID-19 diseases during the pandemic, often for fear of contracting COVID-19, so they would not visit our ED unless necessary. It should be highlighted that not all ED visits represent real emergencies, and inappropriate access to ED is a well-known issue [35]. This could explain the greater decline in ED visits in triages 3,4, and 5 during the pendemic, which was noted in almost all other studies [36–38]. In the post-epidemic period, when the spread of COVID-19 was controlled, we expected to see a progressive increase in ED visits as a consequence of the delay in obtaining medical attention and care access due to the lockdown. Although the total number of patients started to increase, it was still below the pre-epidemic level.
As Taiwan successfully flattened the curve, the CECC lowered the epidemic alert to Level 2. The total number of patients in the ED swiftly increased, but still remained lower than that in the pre-epidemic stage. However, interestingly, the number of older patients who visited the ED for trauma and non-trauma was similar to that in the pre-epidemic stage. To the best of our knowledge, this is the first study demonstrating older patients returning to the ED early when the pandemic slowed down and reached pre-epidemic levels. This could be explained by the fact that this group of patients typically shows higher vulnerability to diseases and is in an urgent need of emergency medical services. Although the older population showed fear of visiting the hospital during the pandemic, they also cared about their chronic disease. For older adults, accessibility to comprehensive care, availability, quality of care, and positive past experiences were key considerations for seeking treatment of non-urgent concerns [39]. The accessibility and convenience of medical services in Taiwan are well known [40]. Furthermore, when facing the COVID-19 epidemic, Taiwan took effective control measures, so the epidemic could be controlled quickly and in a few months [41]. As a result, while the epidemic showed signs of slowing down, the older population immediately sought emergency medical services. It is assumed that, due to advanced age and more comorbidities, the older population was more fragile and had a rigid demand for medical services. As the epidemic slowed down, older individuals returned to the ED to seek medical services earlier. This was a different result from the UK and US hospitals. It showed a great relative reduction in medical admission in the oldest age group, which might be due to concerns about COVID-19 acquisition in the hospital or about the futility of admission [23, 42]. In the general adult group, we could see the trend of climb since the late-epidemic stage, but it did not reach the pre-epidemic level when the lockdown ceased. This could be explained by the difference in health behaviors between the older and middle-aged adults.
At the peak of this community outbreak, there were hundreds of newly diagnosed COVID-19 patients on a daily basis, which had a great impact on our community. At that time, our government also declared a national level 3 epidemic alert, imposing strict lockdown measures and restrictions in an effort to reduce community transmission. These measures included requiring facial coverings in public spaces, banning all social gatherings indoors, and removing all indoor dining by food and beverage vendors. These restrictions were in place to encourage people to stay at home, thus helping to reduce the rate of community transmission with collateral benefits [43]. Our study demonstrated a marked decrease in the number of visiting patients across all groups, including older patient; patients in triage categories 3, 4, or 5; patients visiting for trauma or non-trauma; and patients admitted to the ward or ICU.
However, in our study, triages 1 and 2, which represented emergent and urgent conditions, were unchanged during the whole epidemic, and even in the older group, the number increased slightly since the epidemic developed. This finding was different from that of some previous studies, which demonstrated a significant decline in the number of older adults for acute unscheduled care [30, 44, 45]. Other studies have demonstrated that the volume of highest-acuity patients had the smallest reduction or did not decrease during the pandemic [46, 47]. In Saudi Arabia, which implemented a curfew, a more restrictive measure to control virus transmission, patients presenting during the pandemic were more likely to be more urgent with acuity level [48]. The change in acuity levels of non-COVID-19 ED visits was inconsistent across different countries and cities. Emergent and urgent conditions, including stroke, cardiac problems, and sepsis, are time-dependent. In view of stroke, many studies showed decline in the volume of ischemic stroke/TIA admission, overall stroke admission, and mechanical thrombectomy procedures during the COVID-19 pandemic [49, 50]. The reason was assumed to be the fear of contracting COVID-19, leading many patients with milder stroke presentations to avoid seeking medical attention. Another reason might be related to physical distancing measures, preventing patients from witnessing a stroke in a timely manner. Conversely, acute myocardial infarction was also an emergent condition. Recent studies have shown a significant reduction in ST-elevation myocardial infarction admissions from the United States and Europe during the COVID-19 pandemic [51, 52]. In Taiwan, from February 1 to April 30, 2020, there was no reduction in ST-elevation myocardial infarction admissions [53]. Theoretically, the actual number of emergent and urgent conditions remains unchanged during the COVID-19 pandemic. However, in reality, the number of patients who had emergent and urgent conditions and visited the ED would be influenced by many factors. In our study, the numbers of triages 1 and 2 remained unchanged in the entire epidemic. This finding suggests that the number of patients in this category is less susceptible to the magnitude of the COVID-19 community outbreak and that true emergency medical services remained indispensable throughout the COVID-19 epidemic in Taiwan. This could contribute to adequate public health strategies and easy access to medical care.
Another interesting finding is that in the peak-epidemic period, the emergency admission rate increased in both the general adult and older patient groups. This is a different part compared to other studies [23, 42, 54]. In our hospital, the number of patients admitted from the outpatient department dropped dramatically during the pandemic for several reasons. Fearing COVID-19 acquisition in hospitals, canceling unnecessary surgery, and postponing regular medical treatment are the reasons for the increased hospital bed occupancy rate. Moreover, patients who visited our ED during the pandemic were more likely to require admission. Therefore, although the number of emergency admissions decreased, the emergency admission rate increased during the peak-epidemic stage.
As recurrences of the COVID-19 pandemic are ongoing, our investigation might be useful to understand both the population reaction and healthcare system response at different phases of the epidemic in terms of reduced demand for care and systems capability in intercepting it, especially in geriatrics.