April 22, 2020

Hospitals across the country are reporting that, outside of patients with Covid-19, their EDs are otherwise unsettlingly empty, leaving some observers to question why patients with conditions like heart attacks and strokes are no longer seeking ED care—and leading doctors to ponder potential long-term consequences.

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Physicians, health organizations note decrease in ED visits nationwide

As EDs in some parts of the country have become overrun with patients seeking treatment for Covid-19, the disease caused by the new coronavirus, doctors have noted that the volume of ED visits overall has decreased over the last few weeks—even at hospitals in hard-hit areas like New York and Washington. For example, CNBC reports that data it received from New York City Health + Hospital showed total ED visits at the health system were down by about 50%.

According to CNBC, the American Hospital Association (AHA) has said stay-at-home orders, which are still active in a majority of states, have led to a decrease in patients seeking ED care for conditions other than Covid-19. AHA said the orders "have resulted in less incidents such as accidents and other injuries."

However, while stay-at-home orders may account for a decrease in broken arms and blunt trauma injuries, hospital officials say they're also seeing a decrease in the number of patients with health conditions that often require emergency care, such as heart attacks, stroke, appendicitis, and asthma.

For example, Providence St. Joseph Health said its volume of heart attack patients was down by almost 50% last month when compared with March 2019. Similarly, a report set to be published in the Journal of the American College of Cardiology found that, across nine high-volume cardiac catheterization labs, the rate of patients being treated for a life-threatening cardiac event called STEMI decreased by 38% this March when compared with rates from Jan. 1, 2019, through February 2020.

Health systems also are reporting decreases in the number of stroke patients seeking ED care. Alex Spiotta, director of neurovascular surgery at Medical University of South Carolina (MUSC), said calls from local EDs reporting possible stroke patients decreased from an average 550 calls per month to an average of 100 calls during the first half of April.

'Heart attacks don't stop'

Doctors doubt the decrease in ED visits implies a decrease in the incidence of emergency medical events.

"Even with coronavirus, we still have healthy people who get an illness and need to go to the [ED]," said Christopher Freer, director of emergency medicine at RWJBarnabas Health who also has observed a drop in ED visits at his health system. "Heart attacks don't stop," he said.

Some doctors even said they had expected to see an increase in heart attack patients due to Covid-19, which some data suggests also can damage the heart muscle, the Washington Post reports.

"We should have higher incidences of these events, but we are seeing dramatically fewer in the hospital system," said Mount Sinai cardiovascular surgeon John Puskas.

Doctors suspect that patients who typically would seek treatment at an ED are seeking treatment elsewhere out of fear that they might contract Covid-19 at a hospital or ED.

Fayne Frey, a dermatologist in Rockland County, New York, said she's seen an increase in patients seeking emergency care at her office for conditions like staph infections, infected cuts, and deep lacerations for which they'd usually go to an ED. "I just think there's an overall fear right now of going near urgent care centers and emergency rooms because that's where people with a cough and fever will go," Frey said.

Doctors also worry that patients who are experiencing symptoms of mild heart attacks and strokes are forgoing treatment altogether—which could be dangerous.

Kraftin Schreyer, an emergency medicine doctor at Temple University, said, "We have to assume that the disease prevalence for heart attacks and strokes hasn't changed, which brings me back to the initial concern that patients are trying to manage their complaints at home because they are potentially afraid of getting exposed to virus in a hospital setting."

The 'second health crisis of the year'

Physicians are concerned that patients with severe illnesses who delay or avoid in-person care for their conditions could face long-lasting health consequences—or even death, CNBC reports.

William Pace, an infectious disease doctor in Philadelphia, said he's noticed that "patients who come in with non-Covid-19-related stuff" have been "dying at higher rates," usually after delaying treatment.

Evert Eriksson, trauma medical director at MUSC, said, "What we're seeing is late presentation." For example, Eriksson said, "70% of the appendicitis on my service right now are late presentations," which could harm patients' outcomes.

Doctors said the delays in care also have the potential to overload the U.S. health care system after the country's Covid-19 epidemic dies down. And the impact of delayed medical care could become "the second health crisis of this year," Jonathan Lee Gleason, Jefferson Health's chief quality officer, said.

"If fear of the pandemic leads people to delay or avoid care, then the death rate will extend far beyond those directly infected by the virus," said cardiologist and health care researcher Harlan Krumholz from the Yale School of Medicine. "Time to treatment dictates the outcomes for people with heart attacks and strokes. These deaths may not be labeled Covid-19 deaths, but surely, they are collateral damage."

Krumholz added that hospitals need to advertise that they have protections in place to protect non-Covid-19 patients from contracting the virus and warn that delayed care could lead to a more serious illness or death.

William Gray, a cardiologist at Main Line Health and president of the American Heart Association's Philadelphia chapter, said, "The major message has to be that with a heart attack or heart failure, staying home is not a good place to be," and although many hospitals have temporarily suspended elective procedures, "a heart attack is not elective" (Feuer, CNBC, 4/14; Gantz/Ruderman, Philadelphia Inquirer, 4/21; Bernstein/Sellers, Washington Post, 4/19; Krumholz, New York Times, 4/6).

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