Changes in Emergency Care During the COVID-19 Pandemic at a University Hospital in Barcelona Volume 56- Issue 3

Ana Redondo¹*, Carla Raba Parodi¹, Patricia Oliva¹, Carles Pericas^2,3 and María Grau^4,5,6

• ¹Hospital Universitario Bellvitge, Catalan Institute of Health (ICS), Spain
• ²Department of Medicine, University of Barcelona, Spain
• ³Epidemiology Service, Public Health Agency of Barcelona (ASPB), Spain
• ⁴Biomedical Research Consortium in Epidemiology and Public Health (CIBERESP), Spain
• ⁵Serra Hunter Fellow, Department of Medicine, University of Barcelona, Spain
• ⁶Cardiovascular Risk, Nutrition and Aging, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Spain

Received: May 05, 2024; Published: May 08, 2024

*Corresponding author: Ana Redondo Noya, Universitario Bellvitge, Catalan Institute of Health (ICS), 08907 Barcelona, Spain

DOI: 10.26717/BJSTR.2024.56.008867

Abstract PDF

Purpose: To determinate the impact of the COVID-19 pandemic on emergency department (ED) attendance in 2020 compared to 2019, and to analyze the trend of this change across different waves.
Methods: Descriptive study of ED visits (January 1st, 2019 – December 31st, 2020) at university hospital in Barcelona. The number of emergency cases was analyzed by age, sex, socioeconomic index, triage level, type of discharge, and diagnosis. Three periods were compared: pre-pandemic, first wave, and second wave with the corresponding periods in 2019. The Chi-square test compared proportions.
Results: 84,826 episodes were analyzed. The number of emergencies decreased significantly during both waves, (41.09% and 27.60% respectively) affecting both sexes (p=0.439), all age groups (p<0.001) but in socioeconomic groups, no differences were found. Throughout 2020, non-urgent and less-urgent cases decreased (p <0.001). Visits related to ophthalmological-otorhinolaryngological, and musculoskeletal cases decreased (-41.97% and -36.09% respectively). Conversely, infectious, and parasitic diseases increased substantially (225.39%) due to COVID-19 cases.
Conclusion: The SARS-CoV-2 pandemic reduced in ED attendance among both sexes, across all age and socioeconomic groups, irrespective of the type of pathology being treated.

Keywords: Pandemics; COVID-19; Emergency Service; Health Services Accessibility

Abbreviations: ED: Emergency Department; BUH: University Hospital of Bellvitge; SEI: Socioeconomic Index; ICD-10: International Classification of Diseases, 10th Edition; BHA: Basic Health Area

Coronavirus disease (COVID-19) is a respiratory infection caused by the SARS-CoV-2 coronavirus, which was first reported in Wuhan on December 31st, 2019 [1]. On March 11th, 2020, the World Health Organization declared the COVID-19 a global pandemic [2]. In Spain, a state of alarm was declared on March 14th, 2020, as a measure to control the transmission of the coronavirus. This led to a population lockdown from March 15th to June 21st, 2020 [3]. Following the population lockdown, healthcare activity was affected to attend to COVID-19 cases. Although strategies were implemented to adapt to the health needs, coordination was challenging due to the increased demand for healthcare services and the limited capacity to reorganize the care of chronic diseases [4]. Consequently, in the Central Catalonia health region, there was a 31.1% reduction in the detection of new diagnoses in primary care in 2020 compared to 2019 [5]. Globally, several studies have documented a significant decrease in the utilization of hospital care services during 2020.

This decrease was observed in both the frequency of outpatient visits [6] and in the volume of hospital emergency care attended [7- 9]. Moreover, it has also been noted that emergency department visits for both COVID and non-COVID-related conditions were influenced by certain sociodemographic factors. For instance, emergency department visits among young people decreased [10,11], there was a decline in healthcare service utilization among women [12], and among population with low incomes or limited health coverage [13]. The changes observed during the pandemic varied between countries, as the health response differed in each territory, and the characteristics of each population were different. In Spain, there are limited studies that describe the changes in the frequency of hospital emergency visits and determine if there are any sociodemographic factors associated with these changes. The objective of this study is to analyse the change in the frequency of hospital emergency visits during the year 2020 compared to 2019 considering sociodemographic, clinical, and diagnostic factors and examine the trends of change across different pandemic waves in 2020.

A cross-sectional observational study was conducted on the emergency care attended at the University Hospital of Bellvitge (BUH), a third-level hospital in the city of Barcelona, during the period from January 1st, 2019, to December 31st, 2020. The study included patients attending the emergency department of the hospital’s reference area, aged 18 years or older, and with one or more emergency episodes. Episodes without registration in any of the explanatory variables of interest in the study were excluded. To select the comparison period, the distribution of emergency visits in 2018 and 2019 was analyzed according to the explanatory variables of the study. The distribution was similar in both years, so 2019 was chosen as the comparison period with 2020.

Variables

The variable of interest was the number of emergency visits attended during the study period. This variable was analyzed based on sociodemographic variables: age, sex, and socioeconomic index (SEI); variables related to the episode: triage level and discharge class; and clinical diagnoses classified according to the International Classification of Diseases, 10th edition (ICD-10). Each patient was assigned an SEI based on their Basic Health Area (BHA) of residence. This variable was obtained from information available in the Catalonia Health System Observatory [14], based on the standardized percentage of the population exempt from pharmacy copayment (year 2018) in all BHA of Catalonia. Three categories of SEI were created considering the distribution of the variable in percentiles as follows: low socioeconomic index (≥ 4,7), medium (2,8-4,6), high (≤ 2,7). The triage level was classified into five categories following the Andorran triage model. Thus, an emergency episode with level 1 was considered as immediate urgency, and an emergency episode with level 5 was considered non-urgent [15]. Patients with COVID-19 were identified based on the clinical diagnosis of SARS-CoV-2 disease using the following ICD-10 codes: U07.1, J12.89, B97.29, and B34.2. Three periods were analyzed: pre-pandemic period (January 1st, 2020 - March 11th, 2020), first COVID-19 wave (March 12th, 2020 - April 25th, 2020), and second COVID-19 wave (October 15th, 2020 - November 23rd, 2020) and were compared with the same periods of the previous year. All study variables (except the SEI variable) were obtained from the Minimum Basic Dataset for Emergencies, a mandatory record in Catalonia since 2010.

Statistical Analysis

A descriptive analysis of the number of emergencies attended was conducted using qualitative variables through frequencies and percentages. The chi-square test was used to compare proportions between groups, and Bonferroni correction was applied for multiple comparisons. Statistical significance was established at a p-value of less than 0.05. SPSS version 27.0.0 was used for statistical analysis.

Ethical-Legal Considerations

The study adhered to the guidelines of the International Conference on Harmonization’s Good Clinical Practice and received evaluation and approval from the Clinical Research Ethics Committee of Bellvitge Hospital (Ref. PR189/21).

A total of 84,826 emergency episodes from BUH were analyzed during the period from January 1st, 2019, to December 31st, 2020, meeting the inclusion criteria (Figure 1). Exclusion criteria led to the removal of 1,413 episodes (1.66%) due to missing information on emergency triage level or diagnosis. The distribution of emergencies according to sociodemographic variables was highly similar in both years (Table 1). The percentage of emergencies was higher among women and individuals aged 75 or older. However, during the first wave, the percentage of emergencies among men was higher than that among women (50.50% vs. 49.50%; p=0.041), and the 45-64 age group was the most frequent (p<0.001). There were no significant differences observed between years or waves in terms of socioeconomic status. Regarding the distribution of emergencies based on clinical variables, there was an increase in triage level 2 and a decrease in levels 4 and 5 in 2020 compared to 2019 and across both waves (p<0.001). The percentage of hospital admissions, referrals, and deaths was higher in 2020 and in both waves, with significant differences observed among discharge class categories (p<0.001). The distribution of emergencies among COVID and non-COVID patients differed in certain sociodemographic variables (Table 2). The percentage of COVID-related emergencies was higher in men in both waves (51.58% and 54.30%), although the differences between men and women were not significant. The most frequent age group for COVID patients was 45-64 years (p<0.001).

Figure 1

Table 1: Distribution of emergencies according to sociodemographic and clinical variables in different periods.

Note: ^a1^st January - 11^th March; ^b12^th March - 25^th April; ^c15^th October - 23^rd November; dTriage.
Level 1: inmediate; Level 2: very urgent; Level 3: urgent; Level 4: standard; Level 5: non urgent

Table 2: Distribution of emergencies among COVID and NON-COVID patients according to sociodemographic and clinical variables in different periods.

Note: ^a12^th March - 25^th April; ^b15^th October - 23^rd November; ^cTriage.
Level 1: immediate; Level 2: very urgent; Level 3: urgent; Level 4: standard; Level 5: non urgent

In non-COVID patients, the ≥75 age group was the most frequent in both waves (p<0.001). In terms of clinical variables, the percentage of patients with triage level 2 was higher among COVID patients compared to non-COVID patients in both waves (24.08% vs. 15.22% in the first wave; 56.29% vs. 13.66% in the second wave). Regarding discharge class, the percentage of emergencies resulting in hospital admission was higher among COVID patients compared to non-COVID patients (70.93% vs. 20.73% in the first wave; 59.27% vs. 16.75% in the second wave). In 2020, there was a reduction of -21.85% in the number of attended emergencies compared to 2019. This reduction commenced with the onset of the pandemic (Figure 2) and persisted throughout the year 2020. The maximum reduction peak (-52.61%) occurred in April, and the second peak (-31.38%) was observed in November. The reduction in emergencies affected both men and women equally in both waves (-40.46% and -41.71% in the first wave; -27.04% and -28.15 in the second wave) (Table 3).

Figure 2

Table 3: Reduction in emergencies during 2020 year, first and second pandemic wave according to sociodemographic and clinical variables.

Note: ^a12^th March - 25^th April; ^b15^th October - 23^rd November

It affected all age groups, although the 45-64 age group experienced the smallest reduction throughout the study period. A similar reduction was observed in all three socioeconomic groups during the first wave. In the second wave, the reduction was lower in the less privileged socioeconomic group (-22.72% vs. -28.85% for high SEI and -27.81% for medium SEI). Regarding the analysis by ICD-10 chapters, there was a reduction in emergencies in all chapters except for the chapter of infectious and parasitic diseases, which increased by +225.39% compared to 2019 due to COVID-19 infection. Ophthalmic, otologic, and musculoskeletal disorders experienced the most significant reductions during both the first and second wave (Table 3).

In 2020, attendance at the emergency department of Bellvitge University Hospital decreased by 21.85% compared to 2019. This reduction was more significant during the pandemic waves, with the first wave being the most affected. Similar results were observed in Europe and the USA. In England [11,16] the number of emergencies decreased by 40% during the first wave, and a study conducted in Massachusetts [12] reported a reduction of 30.9% in March-April 2020 compared to the same period in 2019. Possible barriers that could explain this decrease in service utilization during the pandemic have been identified. This includes the fear of contracting COVID-19, the stigma associated with receiving a COVID-19 diagnosis, perceived poor service quality, worsening socioeconomic conditions for patients, increased technological barriers, as well as the perception of minimizing the risk of complications and the need for medical care [17].

In our study, the reduction in emergency department visits affected both men and women similarly. However, some studies have shown that women, especially those with non-COVID-related conditions, had lower utilization of healthcare services [12]. Furthermore, the reduction in the number of emergency visits affects all age groups, with a greater decrease observed in the younger population and the 65-74 age group compared to the previous year. This could be attributed to a decrease in less urgent episodes, especially among young individuals [11], and lower healthcare utilization among chronic patients due to increased concerns about contracting COVID-19 [17]. In our study, unlike in other countries, the average age of patients visiting the emergency department during the first wave did not vary between years. However, hospitals located in Massachusetts and England reported an increase in the average age of approximately 3 years [11,12,16]. Similarly, in Italy and France, the patients attended during the pandemic were also older than usual [10,18]. Regarding socioeconomic status, the utilization of emergency services has maintained a proportional distribution among different groups, and the reductions in each level were similar between both years. However, during the first wave, the analysis by COVID-19 status showed that the less privileged group attended emergency services less frequently. Similar results have been observed in other studies, which found lower emergency department utilization among groups with lower income, limited healthcare coverage [13], or minority ethnicities [12]. Despite this lower utilization, in Anglo-Saxon countries, minority ethnic groups were more represented among those admitted with COVID-19 compared to non-COVID cases [12,16,19]. In non-COVID patients, a lower rate of urgent care attendance has been observed in rural populations [6,20].

In the case of Italy, it was generally found that those who reduced mobility the most were patients from provinces with higher population density, as well as those who were unemployed or working in the industrial or service sectors, with higher levels of education, and the elderly [21]. In 2020, all emergency department visits decreased except for those related to infectious and parasitic diseases, which increased due to COVID-19. The conditions that experienced the most significant reduction in the first wave were eye and ear-related disorders, as well as musculoskeletal disorders. However, these diagnostic groups remained among the most frequently visited in 2020, similar to 2019. These reductions, along with the increase in infectious and parasitic diseases (including COVID-19), align with preliminary studies [22,23]. Other admissions that have been reduced include those for traumatic causes, acute cerebrovascular events, mental health, and dermatological conditions, among others [10,11,18,22-25]. In 2020, an increase in the most urgent triage levels and a decrease in the less urgent levels were observed compared to 2019, consistent with other studies [22].

During the pandemic, there has been an increase in hospital admissions, deaths, and referrals to other centers. Similar to our study, different countries have reported an increased percentage of deaths among non-COVID patients treated in emergency departments in 2020 [10,11,24,26,27]. This study analyzed the total number of emergency department visits by the population in the catchment area of a tertiary-level hospital during the years 2019 and 2020. It is a descriptive study with limitations inherent to this study design, but due to the analysis of all the records, it reflects the change in emergency department utilization that the territory has experienced during the waves of the SARS-CoV-2 pandemic. The criteria for confirming suspected COVID-19 diagnoses and the subsequent coding of the attended emergencies varied throughout the pandemic, which could have led to deviations in the percentages of COVID diagnoses, particularly during the first wave. To minimize this information bias, emergency episodes attended during the first wave of 2020, classified as non- COVID, were cross-checked for suspected SARS-CoV-2 infection (secondary diagnosis or positive diagnostic test).

The socioeconomic level was treated as a cluster variable, assigning each patient the socioeconomic index of the basic health area in which they reside. This classification of patients may not accurately reflect the social reality of the attended emergencies and could, therefore, affect the differences between socioeconomic groups. To determine if the differences found in age groups and the lack of differences between socioeconomic groups were influenced by gender patterns, a gender-stratified analysis was conducted. The results obtained were analogous to those without stratification.

This study identified a reduction in emergency department utilization during the SARS-CoV-2 pandemic. This reduction occurred in both men and women, across all age groups, among different sociodemographic strata of the population, and for all types of pathologies attended in a university teaching hospital emergency department. The findings of this study can serve as a guide to compare and determine the impact of the pandemic on emergency department attendance in different countries. However, it is important to consider that the Catalan healthcare system is publicly accessible and free, which may reduce barriers to accessing medical care.

Mercedes Fernandez Camacho and Raquel Leo n Oyonarte, Care Coding Unit of Bellvitge Hospital, who have contributed to the data generation.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

None.

1. (2019) World Health Organization. Coronavirus disease (COVID-19) pandemic.
2. (2020) World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID- 19.
3. (2020) Boletín Oficial del Estado. Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestion de la situacion de crisis sanitaria ocasionada por el COVID-19.
4. Matenge S, Sturgiss E, Desborough J, Hall Dykgraaf S, Dut G, Kidd M, et al. (2022) Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of international literature. Fam Pract 39(4): 747-761.
5. Pifarre I Arolas H, Vidal Alaball J, Gil J, Lopez F, Nicodemo C, et al. (2021) Missing Diagnoses during the COVID-19 Pandemic: A Year in Review. Int J Environ Res Public Health 18(10): 5335.
6. Alam L, Kazmi SKH, Alam M, Faraid V (2021) Amid COVID-19 pandemic, are non-COVID patients left in the lurch? Pak J Med Sci 37(2): 576-581.
7. Lee KD, Lee SB, Lim JK, Kang YM, Kim IB, et al. (2020) Providing essential clinical care for non- COVID-19 patients in a Seoul metropolitan acute care hospital amidst ongoing treatment of COVID-19 patients. J Hosp Infect 106: 673-677.
8. Frenkel Nir Y, Levy Y, Gutkind A, Grossman E (2021) The effect of the Covid-19 pandemic on patient visits to the emergency department and hospitalizations in medical wards in an Israeli medical center. Isr J Health Policy Res 10(1): 62.
9. Barten DG, Latten GHP, van Osch FHM (2022) Reduced Emergency Department Utilization During the Early Phase of the COVID-19 Pandemic: Viral Fear or Lockdown Effect? Disaster Med Public Health Prep 16(1): 36-39.
10. Lugli G, Ottaviani MM, Botta A, Ascione G, Bruschi A, et al. (2022) The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: A Systematic Review. Mediterr J Hematol Infect Dis 14(1): e2022012.
11. Vollmer MAC, Radhakrishnan S, Kont MD, Flaxman S, Bhatt S, et al. (2021) The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: An observational study. BMC Health Serv Res 21(1): 1008.
12. Baugh JJ, White BA, McEvoy D, Yun BJ, Brown DFM, et al. (2021) The cases not seen: Patterns of emergency department visits and procedures in the era of COVID-19. Am J Emerg Med 46: 476-481.
13. Gonzalez Touya M, Stoyanova A, Urbanos Garrido RM (2021) COVID-19 and Unmet Healthcare Needs of Older People: Did Inequity Arise in Europe? Int J Environ Res Public Heal Artic Public Heal 18: 9177.
14. (2022) Observatorio del Sistema de Salud de Catalun˜a. Central de Resultados.
15. Gomez Jimenez J (2003) Clasificacion de pacientes en los Servicios de urgencias y emergencias: Hacia un modelo de triaje estructurado de urgencias y emergencias. Emergencias 15: 165-174.
16. Reschen ME, Bowen J, Novak A, Giles M, Singh S, et al. (2021) Impact of the COVID-19 pandemic on emergency department attendances and acute medical admissions. BMC Emerg Med 21(1): 143.
17. Pujolar G, Oliver Angles A, Vargas I, Vazquez ML (2022) Changes in Access to Health Services during the COVID-19 Pandemic: A Scoping Review. Int J Environ Res Public Health 19(3): 1749.
18. Wartelle A, Mourad Chehade F, Yalaoui F, Chrusciel J, Laplanche D, et al. (2021) Effect of the COVID-19 pandemic lockdown on non-COVID-19 emergency department visits in Eastern France: Reduced risk or avoidance behavior? Public Health Pract 2: 100109.
19. Vahidy FS, Nicolas JC, Meeks JR, Khan O, Pan A, et al. (2020) Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population. BMJ Open 10(8): e39849.
20. Dhar N, Madhaw G, Kumar M, Kumar N, Tiwari A, et al. (2021) Non-COVID Neurological Emergencies: A Silent Killer Going Unnoticed during COVID-19 Pandemic. J Neurosci Rural Pract 12(3): 461-469.
21. Gauvin L, Bajardi P, Pepe E, Lake B, Privitera F, et al. (2021) Socio-economic determinants of mobility responses during the first wave of COVID-19 in Italy: From provinces to neighborhoods. J R Soc Interface 18(181): 20210092.
22. Gormeli Kurt N, Gunes C (2020) How has Covid-19 pandemic affected crowded emergency services? Int J Clin Pract 74: e13624.
23. Ojetti V, Covino M, Brigida M, Petruzziello C, Saviano A, et al. (2020) Non-COVID Diseases during the Pandemic: Where Have All Other Emergencies Gone? Medicina (Kaunas) 56(10): 512.
24. Santi L, Golinelli D, Tampieri A, Farina G, Greco M, et al. (2021) Non-COVID-19 patients in times of pandemic: Emergency department visits, hospitalizations, and cause-specific mortality in Northern Italy. PLoS One 16(3): e0248995
25. Kastritis E, Tsitsimpis K, Anninos E, Stamatelopoulos K, Kanakakis I, et al. (2020) Significant reduction in the visits to the emergency room department during the COVID- 19 pandemic in a tertiary hospital in Greece: Indirect victims of the pandemic? Medicine (Baltimore) 99(52): e23845.
26. Ben Haim G, Zabatani A, Orion D, Leshem E, Irony A, et al. (2021) The Pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care. Intern Emerg Med 16(8): 2261-2268.
27. Unterberg M, Rahmel T, Rump K, Wolf A, Haberl H, et al. (2022) The impact of the COVID-19 pandemic on non-COVID induced sepsis survival. BMC Anesthesiol 22(1): 12.