ED serves as an important source of public healthcare system for many patients, and they can seek care at any ED, regardless of their ability to pay, and this care is available 24 hours a day. In addition, because of the growth of emergency medicine as a physician specialty, patients see the ED as a source of high-quality care. In many countries the number of ED visits is growing faster than the population [5–7].
In our study, the number of ED visits increased significantly by 17.5–28.4% a year over the past four years, but the trend has been interrupted by the COVID-19 pandemic. In this single-center, retrospective observational study, we report a significant decline (60.9%) in the number of ED visits after outbreak of the COVID-19 pandemic when compared to the pre-COVID period.
ED overcrowding is a serious issue worldwide [8, 9]. This occurs 12–73% of the time according to a nationwide study in the United States . ED overcrowding was attributed to inappropriate use of the ED by a large volume of non-urgent patients. In survey studies, ED overcrowding has been reported to cause delays in diagnosis, delays in treatment, decreased quality of care, and poor patient outcomes. ED overcrowding could potentially affect anyone who suffers unexpected severe illness or injury requiring time sensitive emergency treatment.
China has a large population, and ED overcrowding is widespread in many big cities and has reportedly reached crisis proportions [11, 12]. In China, the most common conditions seen in the ED were acute bronchitis, acute pharyngitis, Sprains and strains, superficial injury and contusion, which are usually not so urgent and don't need emergency-based services.
After the outbreak of COVID-19, the Chinese Government had taken some strict measures to prevent people from gathering or moving unnecessarily. People are required to avoid public places, and wear a mask when going out. These measures have played a key role in cutting off the transmission route of COVID-19, and the most frequent conditions seen in the ED mentioned above have been reduced at the same time. Along with reduction of numbers of the non-urgent patients, ED overcrowding has been relieved. As seen in the study, the waiting time in ED has been greatly reduced. In terms of alleviating ED overcrowding, the pandemic outbreak is not a bad thing, as limited ED resource can be allocated to patients who need emergency care really.
We additionally observed a reduction in the overall number of AIS and ACS patients admitted to our ED and a significant increase in ODT of these patients when comparing the current lockdown period with the same period of 2019 in our study. Reasons for this phenomenon are not understood although some suggest that patients’ fear of exposure to COVID-19 could have contributed to their wait-and-see behavior. The fear of infection and adhering to advice from public health organizations and government officials likely outweighs the concern over mild cardio-cerebrovascular symptoms. Milder symptoms of an acute cardio-cerebrovascular event, which could have historically prompted patients to seek medical attention, receive acute treatment and aggressive secondary prevention, may now be minimized to the point that these patients will stay at home and not present to the emergency room.
Irrespective of the causes, these phenomenon are worrisome, because we all know that AIS and ACS are time dependent diseases, IVT in ischemic stroke and PCI in myocardial infarction are extremely time-sensitive [13–15]. Thrombolysis started within the first 60 minutes after onset is associated with best outcomes for patients with AIS, and over the entire 4.5-hour guideline-endorsed tissue plasminogen activator time window, rates of being disability-free at discharge and discharge to home decay more rapidly in the first 100 to 170 minutes of stroke onset to treatment time, whereas independent ambulation at discharge and in-hospital mortality decline in a linear fashion throughout [16–18]. Short onset to balloon time was associated with lower in-hospital mortality and better long term clinical outcome in patients with myocardial infarction having PCI. Furthermore, a symptom-onset-to-balloon time > 4 h was identified as independent predictor of one-year mortality [19, 20].
We are concerned that the delay in seeking medical care might be accompanied by a substantial increase in post-acute complications and long-term disability even mortality due to the lack of appropriate acute management and implementation of secondary prevention interventions.
To our knowledge, this is the first study to publish data about the impact of the current COVID-19 pandemic on characteristics and trends of ED visits in China, and our study verifies observations recently made by researchers in different countries [21–24].
However, some limitations of the present study should be recognized. The main limitation of this study is the relatively small sample size as a single-center experience. Taking into account the limited population size in the study, multi-center studies enrolling a larger number of patients is desirable to validate our data. Second, there are many critical diseases in ED, but only two of them were chosen in this study for analysis. We think AIS and ACS are the most typical time dependent diseases in ED, and it’s enough to discover the delayed ODT phenomenon through them.