The results showed a sudden decrease in the number of ED visits after the Covid-19 outbreak in 2019 (Fig. 1). The number of ED visits in Kurdistan province has decreased by 57% compared to the comparison period during the first peak of the disease, which is due to fear of disease and social distancing and avoid getting close to patients (20). With a reduction in ED visits, patients may use other networks, which will ultimately affect the public health. Center for Disease Control and Prevention (CDC) also showed in a research that the number of ED visits has decreased after the Covid-19 epidemic, which is consistent with the results of the present research (21). Despite the decrease in ED visits during the covid-19 epidemic and its peaks, the number of patients with confirmed covid-19 symptoms increased during the Covid-19 peaks, which is consistent with the results of the study by Mooly & Jafary's research (22).
The results revealed that the number of trauma-related ED visits has decreased as the number of ED visits decreased after the pandemic, which can be due to the observance of quarantine restrictions, less access to services such as the closure of offices and commercial centers, better social distancing, and reduction of social interactions. Ghafil et al. (2021), witnessed in a study in Los Angeles, a significant decrease in the average weekly trauma admissions during the national quarantine compared to the same period in 2020 (incidence ratio = 0.92) (23). A systematic review of 57 studies from the United Kingdom, Europe, Asia, Australia, New Zealand, and the United States highlighted a global reduction (20.3–84.6%) in trauma cases compared to pre-pandemic years (24). In a previous study on four emergency hospitals in Qatar, the reasons for pre- and post-pandemic ED visits were investigated. The results showed the most significant reduction in the number of ED visits in the heart hospital (33–89%) and the National Cancer Institute (NCI) experienced the least reduction in the patient visits (25), which were consistent with the present study. Goiters showed in a study in Spain that the number of patients decreased by 65.4% during the Covid-19 pandemic compared to the same period in the previous year. The most common reasons for consultations in pediatric ED were related to fever, respiratory infection, and trauma, which is consistent with the results of the present study (26).
The average age of patients before and after the pandemic is 33.5 and 36.9 years, respectively, which has increased by 10.14% after the pandemic. This increase is due to higher infection cases in the elderly population (27). Consistent with the present study, in a study titled "Changes in urban and non-urban patterns of ED use during the Covid-19 epidemic in 28 Michigan hospitals, Daniel Keyes & Black Hardin also reached a similar conclusion (28).
Results showed that 56.5% patients were men and 43.5% were women during a two-year period before the pandemic, but male clients increased by 6% after the pandemic, that is, 62.5% of clients were men and 37.5% were women. This increase in male clients seems to be related to better compliance with safety measures and increasing online health control feedback in women (29). A study has been published on May 30, 2021, the aim of which was to understand gender differences in various psychosocial factors affecting preventive behaviors against Covid-19. Consistent with the present study, the above study reported higher Covid-19-related anxiety and fear levels in women in the earlier stage of the disease than men. Moreover, men adopted preventive behaviors significantly less frequently than women. The above study also revealed that the female participants had a low degree of trust in government measures (30).
The percentages of patients disposed during 6 hours after the first peak of the Covid-19 epidemic increased due to a slight increase in the patient visits. The same situation is evident in December 2020 when this index has increased by 1.69% with a decrease in patient visits. The percentage of patients leaving the ED in a 12-hourhad had more regular pattern and decreased with the onset of the pandemic and the first peak of the disease compared to the same period of the last year. Insufficient equipment and manpower, the increase in the number of visits after a reduction in Covid-19-related anxiety, the shortage of hospital beds, the excess ward capacity and the delayed patient transfer to the relevant wards, a delay in patient counseling and sending the test results, were effective in decreasing this index and decreasing numbers of clients after the Covid-19 pandemic has been one of its increasing factors (31). The results of the present study showed that the organization of non-COVID patients during the pandemic caused a delay in their counselling and a decrease in this index in Kowsar hospital. In a study, Meraji et al. (2019) investigated factors that contribute to changes in these indices. In their study, the index of the percentage of patients leaving the ED in a 12-hour was also reduced, which is consistent with the results of the present study (32). Baratloo & Rahmati (2014) also found in their studies that ED disposition index increased significantly when relevant specialists attended this ward, which are consistent with the present study (33).
The index of discharge against medical advice has increased during the covid-19 epidemic compared to the same period in the previous year. This increase is attributed to the fact that the prolonged Covid-19 detection and the time required to perform x-rays and related tests have increased the waiting time of clients for physician visit. The increase in the ED visits and the waiting time are among the risk factors for discharge against medical advice (34). Wilber et al. showed a higher DAMA when the utilization rate of an emergency department exceeds its capacity. Moreover, about 1.2 million patients, or one percent of all patients, leave the emergency department before treatment is complete (35). Results of a study by Mohsin et al. in a hospital in Australia revealed that a higher rates of young patients (0–29 years) who left emergency departments without being visited as well as clients who have been waiting for triage for a longer period of time and at a lower level of triage. There was a significant relationship between ED overcrowding and the number patients leaving ED (36).
The percentage of pre- and post-pandemic unsuccessful CPR rates were 78.9% and 80%, respectively. Similar studies also did not report a significant relationship (37).
The average duration of triage at each level increased after the covid-19 pandemic compared to before the covid-19 pandemic due to prolonged diagnostic and treatment procedures and the increase in the longer physician appointment wait times. The increase in the number of clients, along with the lack of personnel and resources, leads to ED overcrowding, which in turn affects the waiting time and length of ED stay (38). The average duration of ED triage in different hospitals in Iran has been reported to be very different. For example, the total waiting time for three-level triage in the Emergency Department of Tehran's Haftom-e tir hospital has been announced as 22 minutes (39). This difference seems to be due to the time period of the research. In another study by Baratloo et al., ED overcrowding is attributed the fact that there is no patient leaving the ward, which in turn increases the length of ED stay (33).