Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia

BackgroundMelbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020).MethodsWe used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020.ResultsED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2–4.ConclusionsOur analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne’s lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

A dangerously underrated entity? Non-specific complaints at emergency department presentation are associated with utilisation of less diagnostic resources

Background Patients presenting with non-specific complaints (NSC), such as generalised weakness, or feeling unwell, constitute about 20% of emergency care consultations. In contrast to patients presenting with specific symptoms, these patients experience more hospitalisations, longer stays in hospital and even higher mortality. However, little is known about the actual resources spent on patients with NSC in the emergency department (ED). Methods We have conducted a retrospective analysis from January 1st, 2013 until December 31st, 2017 in a Swiss tertiary care ED to assess the impact of NSC on the utilisation of diagnostic resources in adult patients with highlyurgent or urgent medical complaints. Results We randomly selected 1500 medical consultations from our electronic health record database: The majority of patients (n = 1310, 87.3%) presented with a specific complaint; n = 190 (12.7%) with a NSC. Univariate analysis showed no significant difference in the utilisation of total diagnostic resources in the ED [specific complaints: 844 (577–1313) vs. NSC: 778 (551–1183) tax points, p = 0.092, median (interquartile range)]. A backward selection logistic regression model was adjusted for the identified covariates (age, diabetes, cerebrovascular and liver disease, malignancy, past myocardial infarction, antihypertensive, antithrombotic or antidiabetic medication, night or weekend admission and triage category). This identified a significant association of NSC with lower utilisation of ED diagnostic resources [geometric mean ratio (GMR) 0.91, 95% CI: 0.84–0.99, p = 0.042]. Conclusions Non-specific complaints (NSC) are a frequent reason for emergency medicine consultations and are associated with lower utilisation of diagnostic resources during ED diagnostic testing than with specific complaints.

Nature and extent of selection bias resulting from convenience sampling in the emergency department

BackgroundTo compare the clinical and demographic variables of patients who present to the ED at different times of the day in order to determine the nature and extent of potential selection bias inherent in convenience samplingMethodsWe undertook a retrospective, observational study of data routinely collected in five EDs in 2019. Adult patients (aged ≥18 years) who presented with abdominal or chest pain, headache or dyspnoea were enrolled. For each patient group, the discharge diagnoses (primary outcome) of patients who presented during the day (08:00–15:59), evening (16:00-23:59), and night (00:00-07:59) were compared. Demographics, triage category and pain score, and initial vital signs were also compared.Results2500 patients were enrolled in each of the four patient groups. For patients with abdominal pain, the diagnoses differed significantly across the time periods (p<0.001) with greater proportions of unspecified/unknown cause diagnoses in the evening (47.4%) compared with the morning (41.7%). For patients with chest pain, heart rate differed (p<0.001) with a mean rate higher in the evening (80 beats/minute) than at night (76). For patients with headache, mean patient age differed (p=0.004) with a greater age in the daytime (46 years) than the evening (41). For patients with dyspnoea, discharge diagnoses differed (p<0.001). Asthma diagnoses were more common at night (12.6%) than during the daytime (7.5%). For patients with dyspnoea, there were also differences in gender distribution (p=0.003), age (p<0.001) and respiratory rates (p=0.003) across the time periods. For each patient group, the departure status differed across the time periods (p<0.001).ConclusionPatients with abdominal or chest pain, headache or dyspnoea differ in a range of clinical and demographic variables depending upon their time of presentation. These differences may potentially introduce selection bias impacting upon the internal validity of a study if convenience sampling of patients is undertaken.

Comparison of Outcome Tools Used to Test Mass-Casualty Algorithms in the Pediatric Population

Introduction: Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose. Study Objective: This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients. Methods: An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools. Results: A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The “modified Baxt positive and alive” outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. “Modified Baxt negative and <24 hours LOS” had the highest agreement with the COT green at 89%. Conclusions: Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.

P071 Listening to Beyoncé: factors associated with non-attendance at an outpatient sleep clinic

Introduction Patient non-attendance at outpatient sleep clinics is common and costly. Little is known about the factors associated with sleep clinic non-attendance, especially in an Australian context. The goal of our audit was to identify the patient, referral, and appointment factors that may affect attendance at an outpatient sleep clinic. Methods A case-control study was performed in 171 patients (57 cases / non-attenders and 114 controls / attenders) who had a sleep clinic appointment between September 20th, 2020 and March 21st, 2021. Statistical analysis was performed using the two-sided chi-square test with a 5% significance level. Results The overall rate of non-attendance was 10.8%. The rates of non-attendance between new and review cases were similar. Being single (odds ratio [OR]: 2.49; p = 0.010), middle-aged (OR: 4.39; p &lt; 0.001 vs. older-aged), or female (OR: 2.08; p = 0.026) was associated with a higher rate of non-attendance. English was the primary language for all non-attenders. A higher proportion of non-attenders than attenders were born in Australia. For new cases, the source of referral, reason for referral, and triage category did not affect attendance rates. Likewise, the patient’s primary sleep disorder and treatment status did not affect attendance for review cases. Conclusion Factors associated with non-attendance at an outpatient sleep clinic include being single, middle-aged, or female. By identifying patients at higher risk of clinic non-attendance, a more tailored approach can be developed to mitigate this issue.

P135 An audit investigating the length of time from GP referral to diagnostic polysomnography testing in an Australian tertiary center

Introduction/Aim Obstructive sleep apnoea is increasingly prevalent, with shorter referral to treatment time being associated with improved outcomes. Current studies describe a mean wait-time from initial referral to first outpatient review of 88 days, and from first review to diagnostic polysomnography of 123 days. This quality assurance initiative assessed how our sleep disorders centre in an Australian tertiary hospital compared to existing literature, and attempted to verify how triaging affected wait-time. Methods We retrospectively reviewed patients undergoing diagnostic polysomnography from 1st January 2019 to 30th June 2021. Time from initial referral to first clinic review, plus time from initial review to polysomnography, were recorded. Patient demographics and triage category of requested polysomnography were noted. Microsoft Excel was used to collect data and derive descriptive statistics. Results 380 patients (202-male, 178-female) were included. 251 GP referrals were received. 112 patients were triaged for polysomnography within 30 days of initial review (category 4), 204 patients were triaged within 90 days (category 5), and 44 patients were non-urgent (category 6). Mean number of days between initial referral and first review was 136.13 days. Mean number of days between first review and polysomnography was 28.95 days in category 4, 93.38 days in category 5, and 180 days in category 6. Conclusion Time from initial referral to initial review appeared longer in this study compared to published standards. However, time from initial review to polysomnography appeared shorter. Adjusting patient triaging and/or our ability to see new referrals sooner is required to match the published standards.

Effects of Relaxed Lockdown on Pediatric ER Visits during SARS-CoV-2 Pandemic in Italy

Previously, we demonstrated an 81% reduction in pediatric Emergency Room (ER) visits in Italy during the strict lockdown due to the SARS-CoV-2 pandemic. Since May 2020, lockdown measures were relaxed until 6 November 2020, when a strict lockdown was patchily reintroduced. Our aim was to evaluate the impact of the relaxed lockdown on pediatric ER visits in Italy. We performed a retrospective multicenter study involving 14 Italian pediatric ERs. We compared total ER visits from 24 September 2020 to 6 November 2020 with those during the corresponding timeframe in 2019. We evaluated 17 ER specific diagnoses grouped in air communicable and non-air communicable diseases. We recognized four different triage categories: white, green, yellow and red. In 2020 total ER visits were reduced by 51% compared to 2019 (16,088 vs. 32,568, respectively). The decrease in air communicable diseases was significantly higher if compared to non-air communicable diseases (−64% vs. −42%, respectively). ER visits in each triage category decreased in 2020 compared to 2019, but in percentage, white and red codes remained stable, while yellow codes slightly increased and green codes slightly decreased. Our results suggest that preventive measures drastically reduced the circulation of air communicable diseases even during the reopening of social activities but to a lesser extent with regard to the strict lockdown period (March–May 2020).

Profile and Triage Appropriateness of Trauma Patients Triaged Green: A Prospective Cohort Study from a Secondary Care Hospital in India

Introduction: Triage is an important component of in-hospital trauma care for adequate patient management and to avoid overcrowding in emergency departments (ED). Prioritising the evaluation of non-urgent patients may result in the diversion of workforce from patients requiring immediate care. However, not evaluating these patients may result in missed injuries and poor outcomes. We aimed to evaluate the profile of these non-urgent patients triaged ‘green’, as part of a triage-trial in a secondary-care hospital in India and validate this against the Cape Triage Score (CTS).Methods: We analysed data of patients triaged green in a prospective single-centre cohort study between July 2016 to November 2019. Clinicians at this triage-naive ED were introduced to a triage trial who then assigned a triage category to trauma patients, aged 18 years and above, on initial evaluation. Telephonic follow-up was performed for all patients included in the study. Triage appropriateness was retrospectively analysed using the CTS. Results: We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, 77% males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green, 97% came in as direct arrivals and 94.4% were discharged from the ED after initial evaluation. As per CTS, nearly three-quarters (74%) of patients were undertriaged ‘green’ by the clinicians in a triage-naive ED. Conclusion: ​​ Three-fourths (74%) of the patients triaged green by clinicians in a secondary care hospital in Mumbai were mistriaged when retrospectively analysed using CTS. This highlights the need for implementation and evaluation of trauma triage training for the in-hospital first responders (clinicians, nurses and other paramedical staff) in the EDs.

Impact of COVID-19 Pandemic on Ophthalmic Presentations to an Australian Outer Metropolitan and Rural Emergency Department: A Retrospective Comparative Study

Background To analyse ophthalmic presentations to an outer metropolitan and a rural emergency department (ED) during the COVID-19 pandemic in New South Wales (NSW), Australia. Methods A retrospective comparative study of ophthalmic emergency presentations to Campbelltown Hospital (fifth busiest NSW metropolitan ED; population 310,000) and Bowral and District Hospital (rural ED; population 48,000) before and during COVID-19 was conducted. Patient demographics, triage category, referral source, diagnosis, length of stay, departure status, and follow-up location were assessed from coding data between March 1st to May 31st in 2019 and 2020, corresponding to the peak case numbers and restrictions during COVID-19 in NSW. Differences before and during COVID-19 were analysed using chi-squared tests or independent sample t-tests. Results There was no change in ophthalmic presentations at Campbelltown (n = 228 in 2019 vs. n = 232 in 2020; +1.75%, p = 0.12) and an increase at Bowral (n = 100 in 2019 vs. n = 111 in 2020; +11%, p < 0.01) during COVID-19. Urgent ophthalmic presentations (Triage Category 3) decreased at Bowral (p = 0.0075), while non-urgent ophthalmic presentations (Triage Category 5) increased at both hospitals (Campbelltown p < 0.05, Bowral p < 0.01). Conclusions An upward and varied trend in ophthalmic presentations to an outer metropolitan and a rural ED was observed. Heterogeneous ophthalmic presentation trends at peripheral EDs suggest that a high demand for ophthalmic services remained. A flexible healthcare delivery strategy, such as tele-ophthalmology, may optimise patient care during and after COVID-19.

Factors associated with emergency department length of stay of internal medicine patients

Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.