In this retrospective study, we investigated the impact of the COVID-19 pandemic on ophthalmic presentations to the ED of a busy outer metropolitan and a rural hospital. Results demonstrated that there was no change in total ophthalmic presentation numbers to an outer metropolitan ED (Campbelltown Hospital) and an increase in ophthalmic cases presenting to a rural ED (Bowral and District Hospital) during the pandemic from March 1st to May 31st of 2020, in comparison to the same period in 2019. Surprisingly, both departments saw a corresponding decrease in total emergency presentations during this time period in 2020. With regards to ophthalmic presentations, there was an increase in non-urgent (Triage Category 5) presentations to both EDs, and a decrease in patients presenting with more serious issues such as visual disturbance. In Campbelltown Hospital, we found that there were fewer patients with ophthalmic conditions that did not wait to be seen, as well as a decrease in the length of stay for ophthalmic presentations, however these findings were not replicated in Bowral and District Hospital. On the other hand, Bowral ED saw a significant decrease in urgent (Triage Category 3) ophthalmic-related presentations.
Our finding that total ophthalmic presentation numbers remained unchanged for Campbelltown ED and increased at Bowral ED during COVID-19 is interesting, as it contrasts with other studies that had demonstrated a decline in ophthalmic ED presentations during the pandemic11–17. In particular, a similar analysis conducted in NSW by Kam et al.13 demonstrated a fall of 16% in ophthalmic presentations during a similar time period of 29th March to 31st May at the metropolitan EDs of Western Sydney Local Health District (WSLHD), with return of presentation numbers to those of 2019 in June to July after easing of restrictions. Compared with the hospitals explored in their study, Campbelltown Hospital receives a greater number of patient presentations per year and is more peripherally located in Sydney25, whilst Bowral and District Hospital is a rural hospital southwest of Sydney with fewer per annum presentations. A potential reason for the difference in ophthalmic presentation numbers in our study may be due to the difference in geographical location of these hospitals. There may have been differing perception of sites more affected by COVID-19 amongst the populace, secondary to proximity of identified cases to specific hospitals. This may have affected presentation patterns to these locations. Population relocation to more regional areas26 due to increasing ability of citizens to work from home may have also resulted in an increase in ophthalmic presentations in outer metropolitan and rural hospitals.
Interestingly we found a significant increase in non-urgent (Triage Category 5) presentations to Campbelltown and Bowral EDs in 2020. A breakdown of discharge diagnoses for Category 5 presentations demonstrated that the majority of this increase was due to ocular surface trauma and eye pain (An additional table shows this in more detail [see Additional file 1]). A reason for this may be the reduced access to primary care providers such as general practitioners (GP) or optometrists during the start of the pandemic in NSW and the limitations of GP telemedicine for these eye conditions27. The subjective patient-perceived urgency of their condition, due to ocular surface discomfort and pain, may therefore have caused an increase in ocular surface issues presenting to the emergency department.
In Bowral, there was reduced access to the private ophthalmology referral practice for non-urgent cases during early March 2020 due to physician leave, whilst available ophthalmologists saw urgent cases only. This may also explain the increase in non-urgent ophthalmic presentations during the pandemic at Bowral ED. There was also an agreement between Bowral Hospital and the private ophthalmology practice for patients to be directly reviewed in the private ophthalmology rooms as part of the initial pandemic response in April 2020. Despite the introduction of this referral pathway, our data analysis demonstrated that there was no month-over-month change in ophthalmic presentation and referral patterns in 2020, and many patients presenting to Bowral ED with ophthalmic issues during COVID-19 were still being reviewed by emergency doctors, with only three patients lacking medical assessment documentation during our study period.
Consistent with previous studies, which have shown a drop in presentations for retinal detachments and other causes of visual acuity change or loss11–13, there was a significant decrease in patients presenting with visual disturbances at Campbelltown Hospital ED in our study. There was also a decrease in visual disturbance presentations at Bowral Hospital, but this did not reach significance. As aforementioned, for patients, ocular pain may have eclipsed visual disturbance as an important reason to present to ED during COVID-19. A reduction in identification of patients with visual disturbance may have profound effects on the ongoing burden of vision loss as the pandemic resolves.
There were significantly fewer patients in 2020 at Campbelltown Hospital who left the department before medical assessment, which was also reported by Kam et al.13. This may have been due to a general decrease in case numbers across the emergency department, leading to fewer patients waiting, and was further supported in our study by the significant reduction in length of stay of patients presenting with ophthalmic issues at Campbelltown Hospital. On the other hand, there was no change in the length of stay and number of patients presenting with ophthalmic issues who did not wait for assessment at Bowral ED. This is in the context of increased total ophthalmic-related presentations to this rural ED during 2020, and likely reflects its more streamlined ophthalmological referral pathway that existed prior to the pandemic, for which the private ophthalmology rooms are situated close to the hospital. In contrast to this, patients presenting to the more metropolitan Campbelltown Hospital must utilise private transportation to attend private ophthalmology rooms for review. There was no change in the number of patients being referred for ophthalmology follow-up at both hospitals, suggesting that referral patterns at both EDs did not change significantly with COVID-19, despite changes in types of presentations.
There are several limitations to this study. As a retrospective study of only ED coding data and documentation, the discharge diagnoses of each presentation may not be accurate and does not reflect the final diagnoses made by an ophthalmologist for those patients that received formal specialist review after discharge. However, our study replicated methods used by similar studies13, which did not analyse documentation from ophthalmology follow-up visits. There may also be potential changes in triage criteria in response to the COVID-19 pandemic, as suggested by the differences in discharge diagnoses per triage category in both EDs (An additional table shows this in more detail [see Additional file 1]).
Despite these limitations, our audit incorporates data from two EDs that differ by locality and acuity, which allowed for a comparison of the effect of COVID-19 on ophthalmic ED presentations across NSW. The inclusion of two hospital EDs also increased the sample size of our audit. We had also ensured that the coded discharge diagnoses were correct via individual patient chart reviews of their emergency department presentation, increasing the accuracy of our analysed data.