Fewer presentations to metropolitan emergency departments during the COVID-19 pandemic

Impact of the COVID-19 pandemic from the perspective of patients with cardiovascular disease in Australia: mixed-methods study

OBJECTIVES

The study explored the perceived impacts of COVID-19 and its associated policies and social restrictions on health, self-management and access to healthcare.

DESIGN

Cross-sectional observational (online survey) and qualitative study (semi-structured interviews and thematic analysis).

SETTING

Australia.

PARTICIPANTS

People with self-reported cardiovascular disease (CVD) and/or risk factors.

RESULTS

Survey responses were collected from 690 participants (43.8% women, 40.1% over 65 years). Participants reported that their heart health had been affected by the pandemic (26.3%), were less likely to exercise (47.1%), have a healthy diet (25.9%) and take medications (9.4%). A large proportion were admitted to hospital (46.2%) and presented to the emergency department (40.6%). Difficulties in accessing healthcare providers (53.2%) and use of telemedicine (63.6%) were reported. We conducted 16 semi-structured interviews and identified five key themes: adding burden in seeking medical care, impediments in accessing a readjusted health system, exacerbating vulnerability and distress, coping with self-management and adapting to telehealth.

CONCLUSIONS

Patients with CVD expressed an additional burden in seeking medical care and difficulties navigating a readjusted health system during the COVID-19 pandemic. Associated policies and access issues heightened vulnerabilities and distress, making self-management of health difficult for patients with CVD.

The impact of COVID-19 on adult burns: A statewide review of epidemiology and clinical outcomes

INTRODUCTION

The COVID-19 pandemic has significantly impacted the clinical presentations of burns and the provision of services. This study aims to describe and analyse patterns and trends in adult burns across New South Wales (NSW) and the Australian Capital Territory.

METHODS

A NSW statewide retrospective review was conducted from 2017 to 2022 for adult patients with burns. A comparative analysis was performed for the COVID-19 group (2020-2022) and control group between 2017 and 2019.

RESULTS

We found a total of 11,433 patients (7102 non-COVID vs 4331 COVID-19). The average age in the COVID-19 group was 1.4 years older than counterparts (40.6 vs 42.0, p < 0.001). The 18 - 25 and 36 - 45 age groups experienced significantly lower proportions of presentations, whereas, the 76-85 years experienced significantly higher proportions. There was a significantly higher proportion of pressure injuries (0.1% vs 0.4%, p < 0.001) and contact burns (17.2% vs 18.7%), but lower explosions (1.3% vs 0.2%) for the COVID-19 group compared to their counterparts. The mean TBSA% was 0.4% greater in the COVID-19 group compared to their counterparts (2.4 vs 2.8, p < 0.001). There were significantly more operating sessions (0.2 vs 0.3, p < 0.001). The mean length of stay was significantly greater by 0.8 days for the COVID-19 group compared to their counterparts (1.5 vs 2.3, p < 0.001).

CONCLUSIONS

Epidemiological changes were not greatly different to previous years from the impact of COVID-19. The shift in elderly presentations and operative interventions reflects the holistic care of burns units working in a new landscape with an invigorated focus on telehealth and outpatient care.

Trends in blood pressure changes and hypertension prevalence in Australian adults before and during the COVID-19 pandemic

Efforts to limit the impact of the coronavirus disease (COVID-19) pandemic led to the implementation of public health measures and reallocation of health resources. To investigate trends in blood pressure (BP), hypertension and BMI in the Australian population during the COVID-19 pandemic, data from publicly accessible health stations were analyzed. Average BP and BMI measured by the SiSU Health Station network in Australia in over 1.6 million health screenings were compared between the years 2018 and 2021. Additionally, paired trajectories for BP and BMI development before and during the COVID-19 pandemic were calculated. Comparisons between pre-COVID years and post-COVID years of 2018 versus 2020, 2019 versus 2020, 2018 versus 2021, and 2019 versus 2021 showed increases in average adjusted systolic BP of 2.0, 1.7, 2.6, and 2.3 mmHg, respectively. Paired analysis of longitudinal data showed an overall increase in the trajectory of systolic BP of 3.2 mmHg between pre- and post-COVID years. The prevalence of hypertension in users of the health stations increased by approximately 25% in the years 2020-2021. Similar trends were seen for BMI. Data from public Australian health stations indicated a strong trend toward higher BP during the COVID-19 pandemic. At the population level, BP increments have been shown to markedly increase cardiovascular disease risk. Anti-pandemic measures need to be carefully evaluated in terms of secondary public health effects and health support systems extended to effectively target cardiovascular risk.

Telehealth Rapid Access Chest Pain Clinic: Initial Experience During COVID-19 Pandemic

Objectives: Rapid Access Chest Pain Clinics (RACPCs) provide safe and efficient follow-up for outpatients presenting with new-onset chest pain. RACPC delivery by telehealth has not been reported. We sought to evaluate a telehealth RACPC established during the coronavirus disease 2019 (COVID-19) pandemic. There was a need to reduce the frequency of additional testing arranged by the RACPC during this time, and the safety of this approach was also explored. Methods: This was a prospective evaluation of a cohort of RACPC patients reviewed by telehealth during the COVID-19 pandemic compared with a historical control group of face-to-face consultations. The main outcomes included emergency department re-presentation at 30 days and 12 months, major adverse cardiovascular events at 12 months, and patient satisfaction scores. Results: One hundred forty patients seen in the telehealth clinic were compared with 1,479 in-person RACPC controls. Baseline demographics were similar; however, telehealth patients were less likely to have a normal prereferral electrocardiogram than RACPC controls (81.4% vs. 88.1%, p = 0.03). Additional testing was ordered less often for telehealth patients (35.0% vs. 80.7%, p < 0.001). Rates of adverse cardiovascular events were low in both groups. One hundred twenty (85.7%) patients reported being satisfied or highly satisfied with the telehealth clinic service. Conclusions: In the setting of COVID-19, a telehealth RACPC model with reduced use of additional testing facilitated social distancing and achieved clinical outcomes equivalent to a face-to-face RACPC control. Telehealth may have an ongoing role beyond the pandemic, supporting specialist chest pain assessment for rural and remote communities. Pending further study, it may be safe to reduce the frequency of additional testing following RACPC review.

Disposition of patients utilising the virtual emergency department service in southeast region of Melbourne (SERVED-1)

OBJECTIVE

Supported by the state government, three health networks partnered to initiate a virtual ED (VED), as part of a broader roll-out of emergency telehealth services in Victoria. The aim of the present study (Southeast Region Virtual Emergency Department-1 [SERVED-1]) was to report the initial 5-month experience and included all patients assessed through the service over the first 5 months (1 February 2022 to 30 June 2022).

METHODS

VED consults occurred after referral from paramedics in the pre-hospital setting. Electronic medical records were retrospectively reviewed for demographic, presenting complaint and outcome data. The primary outcome was the count of VED consultations. The secondary outcome was the proportion of patients where physical ED attendance was avoided within 72 h. The proportion of physical ED attendances avoided sub-grouped by primary presenting complaints were reported.

RESULTS

There were 1748 patients who had a VED consultation, of which 1261 (72.1%; 95% confidence interval [CI] 70.0-74.2) patients had physical presentation to an ED avoided in the 72 h following the consult. There was a significant increase in consultations over the 5-month period (incidence rate ratio 1.27; 95% CI 1.23-1.31, P < 0.001) that was consistent in the three health services. The most common presenting complaints were COVID-19 and shortness of breath, and physical presentation was avoided most often among younger patients and those with COVID-19.

CONCLUSIONS

Initial experience demonstrated a significant increase in adoption of the service and an overall avoidance of physical ED attendance by a majority of patients. These results support ongoing VED consultations, complemented by follow up and health economic evaluations.

Exploration of Cardiology Patient Hospital Presentations, Health Care Utilisation and Cardiovascular Risk Factors During the COVID-19 Pandemic

OBJECTIVES

COVID-19 and the lockdowns have affected health care provision internationally, including medical procedures and methods of consultation. We aimed to assess the impact of COVID-19 at two Australian hospitals, focussing on cardiovascular hospital admissions, the use of community resources and cardiovascular risk factor control through a mixed methods approach.

METHODS

Admissions data from the quaternary referral hospital were analysed, and 299 patients were interviewed from July 2020 to December 2021. With the admissions data, the number, complexity and mortality of cardiology hospital admissions, prior to the first COVID-19 lockdown (T0=February 2018-July 2019) were compared to after the introduction of COVID-19 lockdowns (T1=February 2020-July 2021). During interviews, we asked patients about hospital and community health resource use, and their control of cardiovascular risk factors from the first lockdown.

RESULTS

Admission data showed a reduction in hospital presentations (T0=138,099 vs T1=128,030) and cardiology admissions after the lockdown period began (T0=4,951 vs T1=4,390). After the COVID-19-related lockdowns began, there was an increased complexity of cardiology admissions (T0=18.7%, 95% CI 17.7%-19.9% vs T1=20.3%, 95% CI 19.1%-21.5%, chi-square test: 4,158.658, p<0.001) and in-hospital mortality (T0=2.3% of total cardiology admissions 95% CI 1.9%-2.8% vs T1=2.8%, 95% CI 2.3%-3.3%, chi-square test: 4,060.217, p<0.001). In addition, 27% of patients delayed presentation due to fears of COVID-19 while several patients reported reducing their general practitioner or pathology/imaging appointments (27% and 11% respectively). Overall, 19% reported more difficulty accessing medical care during the lockdown periods. Patients described changes in their cardiovascular risk factors, including 25% reporting reductions in physical activity.

CONCLUSION

We found a decrease in hospital presentations but with increased complexity after the introduction of COVID-19 lockdowns. Patients reported being fearful about presenting to hospital and experiencing difficulty in accessing community health services.

Emergency department presentations during the COVID-19 pandemic in Queensland (to June 2021): interrupted time series analysis

OBJECTIVES

To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers.

DESIGN

Interrupted time series analysis.

SETTING

All 105 Queensland public hospital EDs.

MAIN OUTCOME MEASURES

Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers).

RESULTS

During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12-month post-lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis.

CONCLUSIONS

The COVID-19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs.

Calling an ambulance for non-emergency medical situations: Results of a cross-sectional online survey from an Australian nationally representative sample

OBJECTIVE

To investigate the Australian general public's perception of appropriate medical scenarios that warrants a call to an emergency ambulance.

METHODS

An online survey asked participants to identify the likely medical treatment pathway they would take for 17 hypothetical medical scenarios. The number and type of non-emergency scenarios (n = 8) participants incorrectly suggested were appropriate to place a call for an emergency ambulance were calculated. Participants included Australian residents (aged >18 years) who had never worked as an Australian registered medical doctor, nurse or paramedic.

RESULTS

From a sample of 5264 participants, 40% suggested calling an emergency ambulance for a woman in routine labour was appropriate. Other medical scenarios which were most suggested by participants to warrant an emergency ambulance call was 'Lego in ear canal' (11%), 'Older person bruising' (8%) and 'Flu' (7%). Women, people aged 56+ years, those without a university qualification, with lower household income and with lower emotional wellbeing were more likely to suggest calling an emergency ambulance was appropriate for non-emergency scenarios.

CONCLUSIONS

Although emergency healthcare system (EHS) capacity not increasing at the same rate as demand is the biggest contributor to EHS burden, non-urgent medical situations for which other low-acuity healthcare pathways may be appropriate does play a small role in adding to the overburdening of the EHS. This present study outlines a series of complaints and demographic characteristics that would benefit from targeted educational interventions that may aid in alleviating ambulance service attendances to low-acuity callouts.

Adapting the 'First 2000 Days maternal and child healthcare framework' in the aftermath of the COVID-19 pandemic: ensuring equity in the new world

The purpose of this perspective article is to emphasise the importance of the 'First 2000 Days' policy of life from conception to age five, and to propose new directions in which the policy's implementation could be extended for the benefit of children and families. The proposed approach highlights principles of responsiveness, integration, sustainability and equity, specifying initiatives that embody the kind of innovation each principle aspires to. The article also proposes innovations in data collection and linkages that would strengthen the implementation of first 2000 days policies and frameworks. This perspective proposes a framework that could improve health systems implementation of services in the first 5 years of life, by proposing a well-coordinated continuum of services with integrated physical and digital solutions. This has the potential to transform how the health system monitors and responds to children and families' needs in the critical early years of life during and beyond the current pandemic.

Inborn errors of metabolism refuse to stay-at-home: Experiences of a state-wide biochemical genetics service during the COVID-19 pandemic

AIM

The New South Wales (NSW) biochemical genetics (BG) service in Australia developed business continuity plans (BCPs) in response to the COVID-19 pandemic to ensure the essential service remained operational. This article aims to discuss the effects of the COVID-19 BCPs on the NSW BG service and patient care.

METHODS

BCPs were developed that included charting of NSW BG service workflow and services against staff resources and clinical impact on patients. The effect of the BCPs was analysed quantitatively by reviewing key performance indicators (result turnaround time, frequency and severity of clinical incidents and laboratory nonconformities) and qualitatively from staff feedback generated by a BG laboratory-wide survey.

RESULTS

Alternative BCPs were implemented during the pre-defined period March 2020 to November 2021 (inclusive), to reflect changes in COVID-19 community transmission, vaccination rates; and health orders. Operation of our essential pathology service was maintained, with no significant difference observed in key performance indicators when compared to pre-COVID. During the pre-defined period of the COVID-19 pandemic, staff reported increased levels of both work- and out-of-work-related stress.

CONCLUSION

The successful continuation of the BG service, with no statistically significant impact on patient care and delivery of essential services, can be attributed to strategic planning and timely implementation of these BCPs. In conjunction with the resilient and robust attitude of the staff during this ever-changing situation, this experience has served as an invaluable tool for future disaster management planning.

The "affected" pharmacist and the "business as usual" pharmacist: Exploring the experiences of pharmacists during COVID-19 through cluster analysis

BACKGROUND

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated considerable changes in the delivery of pharmacy services, with pharmacists experiencing increasing demands and a high rate of burnout. The ability to categorize pharmacists based on their burnout risk and associated factors could be used to tailor burnout interventions.

OBJECTIVE

This study aimed to identify subgroups (profiles) of pharmacists and use these profiles to describe interventions tailored to improve pharmacist's well-being.

METHODS

A survey was disseminated to pharmacists working in Australia during April and June 2020. The survey measured demographics, burnout, and psychosocial factors associated with working during COVID-19. A two-step cluster analysis was used to categorize pharmacists based on burnout and other variables.

RESULTS

A total of 647 survey responses contained data that were used for analysis. Participants were mostly female (75.7%) and working full time (65.2%). The final cluster analysis yielded an acceptable two-cluster model describing 2 very different pharmacist experiences, using 10 variables. Cluster 2 (representing 53.1% of participants) describes the "affected" pharmacist, who has a high degree of burnout, works in community pharmacy, experiences incivility, is less likely to report sufficient precautionary measures in their workplace, and has had an increase in workload and overtime. In contrast, cluster 1 (representing 46.9% of participants) describes the profile of a "business as usual" hospital pharmacist with the opposite experiences. Interventions focused on the "affected" pharmacist such as financial support to employ specialized staff and equitable access to personal protective equipment should be available to community pharmacists, to reduce the risk to these frontline workers.

CONCLUSION

The use of cluster analysis has identified 2 distinct profiles of pharmacists working during COVID-19. The "affected" pharmacist warrants targeted interventions to address the high burnout experienced in this group.

The effects of the COVID-19 pandemic on drug and poison–related deaths in Gold Coast, Australia

Introduction

COVID-19 is postulated to impact drug- and poison-related deaths. America has reported an increased in drug-related deaths, whereas Australia has reported a decline. Regional studies are scant and may not mirror national data. Characterising drug and poison–related deaths during COVID-19 at a regional level would inform local interventions and policies on the current and future pandemics.

Methods

A 4-year retrospective study from January 1, 2018, to December 31, 2019 (pre-COVID-19 pandemic) and from January 1, 2020, to December 31, 2021 (COVID-19 pandemic) of all drug and poison–related deaths admitted to the Gold Coast University Hospital under Coronial investigation.

Results

Drug and poison–related deaths increased in both the proportion and absolute numbers before and during the COVID-19 pandemic. There was no statistical difference in age, sex, location of death, manner of death and classification of drugs and poison implicated.

Conclusions

Although there is an increase in drug and poison–related deaths, the overall demographic and pattern have not changed. Further studies to account for the variation may enable implementation of targeted public health interventions to address the burden of related deaths in regional settings in the context of future pandemics.

Management of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic profoundly impacted delivery of health care. South Western Sydney Local Health District (SWSLHD) experienced some of the highest cases, admissions and deaths during the Delta and Omicron waves in New South Wales. This study aims to determine the impact of the pandemic on emergency surgery services for adults presenting with acute appendicitis.

METHODS

A retrospective review of patient records was performed of adults presenting with acute appendicitis between 1st March 2021 and 31st March 2022, which was compared to a pre-COVID control period of the same dates in 2019-2020. Patients managed operatively or conservatively were included.

RESULTS

1556 patients were included in the operative arm; 723 and 833 respectively in the study and control groups, which were comparable at baseline. 1.66% were COVID positive. During the pandemic, patients were significantly more likely to be investigated with computered tomography (CT) scan (p ≤ 0.001), present with complicated appendicitis (p = 0.03), and require caecectomy (p = 0.005). They had higher American Society of Anaesthesiology (ASA) scores (p = 0.001) and significantly lower negative appendectomy rates (p = 0.001). Fifty-two patients were included in the conservative arm; 29 and 23 respectively in the pandemic and control groups. Patients were comparable at baseline. There were two COVID positive patients. During the pandemic, there was a significant reduction in complications (p = 0.033), readmissions (0.044) and interval appendicectomy (p = 0.0044).

CONCLUSION

We identified higher rates of complicated appendicitis, caecectomies and greater reliance on CT imaging preoperatively during the pandemic in SWSLHD.

Temporal trends in cardiovascular care: Insights from the COVID-19 pandemic

In response to the ongoing COVID-19 pandemic, public health care measures have been implemented to limit spread of the contagion and ensure adequate healthcare resource allocation. Correlating with these measures are observed changes in the incidence and outcomes of cardiovascular conditions in the absence of COVID-19 infection. The pandemic has resulted in a reduction in acute coronary syndrome, heart failure and arrhythmia admissions but with worsened outcomes in those diagnosed with these conditions. This is concerning of an underdiagnosis of cardiovascular diseases during the pandemic. Furthermore, cardiovascular services and investigations have decreased to provide healthcare allocation to COVID-19 related services. This threatens an increasing future prevalence of cardiovascular morbidity in healthcare systems that are still adapting to the challenges of a continuing pandemic. Adaption of virtual training and patient care delivery platforms have been shown to be useful, but adequate resources allocation is needed to ensure effectiveness in vulnerable populations.

Narrative Review of New Insight into the Influence of the COVID-19 Pandemic on Cardiovascular Care

Background and Objectives: The purpose of this paper was to perform a literature review on the effects of the COVID-19 pandemic on cardiothoracic and vascular surgery care and departments. Materials and Methods: To conduct this evaluation, an electronic search of many databases was conducted, and the resulting papers were chosen and evaluated. Results: Firstly, we have addressed the impact of COVID-19 infection on the cardiovascular system from the pathophysiological and treatment points of view. Afterwards, we analyzed every cardiovascular disease that seemed to appear after a COVID-19 infection, emphasizing the treatment. In addition, we have analyzed the impact of the pandemic on the cardiothoracic and vascular departments in different countries and the transitions that appeared. Finally, we discussed the implications of the cardiothoracic and vascular specialists' and residents' work and studies on the pandemic. Conclusions: The global pandemic caused by SARS-CoV-2 compelled the vascular profession to review the treatment of certain vascular illnesses and find solutions to address the vascular consequences of COVID-19 infection. The collaboration between vascular surgeons, public health specialists, and epidemiologists must continue to investigate the impact of the pandemic and the response to the public health issue.

Toxicology presentations to a tertiary unit in New South Wales during the COVID-19 pandemic first wave: A retrospective comparison study

OBJECTIVE

To compare presentation numbers, class of exposure, poison severity score (PSS) and drugs ingested by patients in a tertiary toxicology service during the first wave of the COVID-19 pandemic to the corresponding time periods in 2018 and 2019.

METHODS

A retrospective cohort observational study of patients admitted or consulted to the Western Sydney Toxicology Service (WSTS) from ED during February to May in 2018-2020. Patient age, sex, triage category, time and date of arrival, mode of arrival, type of poisoning, discharge location, length of stay and PSS were collected from WSTS database and electronic medical records. The total number of ED presentations, hospital admissions and toxicology admissions were gathered from hospital-based data services.

RESULTS

There was an overall increase in toxicology presentations in February to May 2020 (n = 441) compared to 2019 (n = 333) and 2018 (n = 255). The daily rate of presentations increased in March to May 2020 with an overall rate ratio of 1.42, 95% confidence interval 1.23-1.63, P < 0.001. There was an increase in presentations across all drug types. From March to April 2020, there was significantly higher number of daily presentations for recreational drugs use compared to 2018.

CONCLUSION

There was a relative increase in toxicology presentations during the COVID-19 pandemic compared to an overall decrease in presentations to ED. Recreational drug use increased significantly during the pandemic compared to 2018.

Imaging volumes during COVID-19: A Victorian health service experience

BACKGROUND

The World Health Organisation declared the coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020. While globally, the relative caseload has been high, Australia’s has been relatively low. During the pandemic, radiology services have seen significant changes in workflow across modalities and a reduction in imaging volumes.

AIM

To investigate differences in modality imaging volumes during the COVID-19 pandemic across a large Victorian public health network.

METHODS

A retrospective analysis from January 2019 to December 2020 compared imaging volumes across two periods corresponding to the pandemic’s first and second waves. Weekly volumes across patient class, modality and mobile imaging were summed for periods: wave 1 (weeks 11 to 16 for 2019; weeks 63 to 68 for 2020) and wave 2 (weeks 28 to 43 for 2019; weeks 80 to 95 for 2020). Microsoft Power Business Intelligence linked to the radiology information system was used to mine all completed examinations.

RESULTS

Summed weekly data during the pandemic’s first wave showed the greatest decrease of 29.8% in adult outpatient imaging volumes and 46.3% in paediatric emergency department imaging volumes. Adult nuclear medicine demonstrated the greatest decrease of 37.1% for the same period. Paediatric nuclear medicine showed the greatest decrease of 47.8%, with angiography increasing by 50%. The pandemic’s second wave demonstrated the greatest decrease of 23.5% in adult outpatient imaging volumes, with an increase of 18.2% in inpatient imaging volumes. The greatest decrease was 28.5% in paediatric emergency department imaging volumes. Nuclear medicine showed the greatest decrease of 37.1% for the same period. Paediatric nuclear medicine showed the greatest decrease of 36.7%. Mobile imaging utilisation increased between 57.8% and 135.1% during the first and second waves. A strong correlation was observed between mobile and non-mobile imaging in the emergency setting (Spearman’s correlation coefficient = -0.743, P = 0.000). No correlation was observed in the inpatient setting (Spearman’s correlation coefficient = -0.059, P = 0.554).

CONCLUSION

Nuclear medicine was most impacted, while computed tomography and angiography were the least affected by the pandemic. The impact was less during the pandemic’s second wave. Mobile imaging shows continuous growth during both waves.

COVID-19 Pandemic Impact on Percutaneous Coronary Intervention for Acute Coronary Syndromes: An Australian Tertiary Centre Experience

Background

Countries who suffered large COVID-19 outbreaks reported a decrease in acute coronary syndrome (ACS) presentations and percutaneous coronary intervention (PCI). The impact of the pandemic in countries like Australia, with relatively small outbreaks yet significant social restrictions, is relatively unknown. There is also limited and conflicting data regarding the impact on clinical outcomes, symptom-to-door time (STDT) and door-to-balloon time (DTBT).

Methods

Consecutive ACS patients treated with PCI were prospectively recruited from a tertiary hospital network in Melbourne, Australia. The pre-pandemic period (11 March 2019–10 March 2020) was compared to the pandemic period (11 March 2020–10 May 2020) using an interrupted time series analysis with a primary endpoint of number PCI-treated ACS per day. Secondary endpoints included STDT, DTBT, total mortality and major adverse cardiac events (MACE).

Results

A total 984 ACS patients (14.8% during the pandemic period) received PCI. Mean number of PCI-treated ACS per day did not differ between the two periods (2.3 vs 2.4, p=0.61) with no difference in STDT [+51.3 mins, 95% confidence interval (CI) -52.4 to 154.9, p=0.33], 30-day mortality (5% vs 5.3%, p=0.86) or MACE (5.2% vs 6.1%, p=0.68). DTBT was significantly longer during the pandemic versus the pre-pandemic period (+18.1 mins, 95% CI 1.6–34.5, p=0.03) and improved with time (slope estimate: -0.76, 95% CI -1.62 to 0.10).

Conclusions

Despite significant social restrictions imposed in Melbourne, numbers of ACS treated with PCI and 30-day outcomes were similar to pre-pandemic times. DTBT was significantly longer during the COVID-19 pandemic period, likely reflecting infection control measures, which reassuringly improved with time.

COVID-19 Impact on Australian Patients with Substance Use Disorders: Emergency Department Admissions in Western Sydney before Vaccine Roll Out

Background: In this study, we determined the impact of the COVID-19 pandemic on Western Sydney patients with substance use disorders (SUD) by comparing emergency department (ED) admission rates before and after the onset of the COVID-19 pandemic and before the rollout of COVID-19 vaccination. Methods: ED admission data for patients with SUD were retrieved from the local electronic medical record (eMR) on the hospital central database. ED data collected from 25 January to 25 July 2019 (before the COVID-19 pandemic) were compared with data from 25 January to 25 July 2020 (early pandemic). ED admission reasons were categorised based on the presenting complaints and ED diagnoses. Results: Despite an overall reduction in ED admissions during the early pandemic, compared to the pre-pandemic period, admissions for patients with SUD increased significantly (1.7% to 3.4%, p < 0.01). ED admission rates related to infection (0.05% to 0.12%, p < 0.01), local infection (0.02% to 0.05%, p < 0.01), trauma (0.06% to 0.12%, p < 0.01), alcohol (0.01% to 0.03%, p < 0.05), and other issues (0.06% to 0.10%, p < 0.05) increased significantly among Indigenous patients with SUD. ED admission rates related to drugs (0.12% to 0.39%, p < 0.01), infection (0.21% to 0.34%, p < 0.01), local infection (0.07% to 0.18%, p < 0.01), gastrointestinal (0.15% to 0.23%, p < 0.05), trauma (0.14% to 0.25%, p < 0.01), alcohol (0.36% to 0.74%, p < 0.01), and ‘other’ issues (0.47% to 0.91%, p < 0.01) increased significantly among non-Indigenous patients with SUD. Four cases of COVID-19 were reported among these patients. Conclusions: There was an increase in ED admissions for patients with SUD in the initial six months of the COVID-19 pandemic (before vaccine rollout), mainly for drugs, systemic infection, local infection, trauma, and alcohol-related reasons. Now that most people in New South Wales have been vaccinated against COVID-19, a further study is needed to quantify the effect of the pandemic on patients with SUD in the post-vaccine era.

The impact of COVID-19 on antipsychotic prescriptions for patients with schizophrenia in Australia

OBJECTIVE

To assess the impact, in the Australian setting, of the COVID-19 lockdown on antipsychotic supplies for patients with schizophrenia following a prescription from a new medical consultation when compared to the same periods in the previous 4 years. A secondary objective was to assess the volume of all antipsychotic supplies, from new and repeat prescriptions, over these same periods.

METHODS

A retrospective pharmaceutical claims database study was undertaken, using the Department of Human Services Pharmaceutical Benefits Scheme 10% sample. The study population included all adult patients with three or more supplies of oral or long-acting injectable antipsychotics for the treatment of schizophrenia at any time between 1 June 2015 and 31 May 2020. The primary outcome compared volumes of dispensed antipsychotics from new prescriptions (which require a medical consultation) between 1 April and 31 May each year from 2016 to 2020. This was to analyse the period during which the Australian Government imposed a lockdown due to COVID-19 (April to May 2020) when compared the same periods in previous years.

RESULTS

There was a small (5.7%) reduction in the number of antipsychotics dispensed from new prescriptions requiring a consultation, from 15,244 to 14,372, between April and May 2019 and the same period in 2020, respectively. However, this reduction was not statistically significant (p = 0.75) after adjusting for treatment class, age, gender, location and provider type.

CONCLUSION

The COVID-19 restrictions during April and May 2020 had no significant impact on the volume of antipsychotics dispensed from new prescriptions for patients with schizophrenia when compared to the volume of antipsychotics dispensed from new prescriptions during the same period in previous years.

Reduced number of admissions with acute appendicitis but not severe acute appendicitis at two Sydney hospitals during the first COVID-19 lockdown period

Background

This study investigated whether there was a change in acute appendicitis, appendicectomy admissions or disease severity during the 2020 lockdown period in NSW.

Methods

A retrospective before‐and‐after study was undertaken of patients admitted to two Sydney hospitals (St. Vincent's and Liverpool Hospitals) who had appendicectomy for presumed acute appendicitis and patients who had confirmed appendicitis but did not undergo surgery. Study periods were the 2020 lockdown period (15 March–15 May 2020), the corresponding period in the previous year, and the 1‐month after these periods. Patients were classified as having no, mild or severe appendicitis using operation and histopathological reports.

Results

(Thirty‐six percent) fewer patients were admitted with acute appendicitis during the lockdown period compared with the previous year with a substantial reduction in normal/mild appendicitis presentations (OR 0.56, 95% CI 0.34–0.93, P = 0.03). There were 46% fewer patients with mild appendicitis during lockdown (56) compared with the previous year (103); numbers of patients with severe appendicitis were very similar (46 vs. 51). There was no increase in number of admissions with severe appendicitis, or in the time from onset of symptoms to admission, in the month following lockdown.

Conclusion

Compared with the previous year, there were markedly fewer admissions with appendicitis during lockdown, with no evidence of a shift to more cases of severe appendicitis nor delayed presentation in the post‐lockdown period. It is plausible that some patients with mild appendicitis may have recovered without hospitalization, supporting the importance of implementing trials on non‐surgical management of appendicitis.

During COVID‐19 lockdown in Sydney we noted a reduction in hospital presentations with acute appendicitis but not severe acute appendicitis. Mild appendicitis may be able to be successfully managed in the outpatient setting.

The impact of the first wave of COVID-19 on stroke admissions across three tertiary hospitals in Brisbane

Background

COVID‐19 has caused a global shift in healthcare‐seeking behaviour; however, presentation rates with serious conditions, such as stroke in low COVID‐19‐prevalence cities, has received less attention.

Aims

To determine if there was a significant reduction in stroke admissions, delivery of acute reperfusion therapies, or increased delays to presentation during the first wave of the COVID‐19 pandemic.

Methods

A multicentre, retrospective, observational cohort study was performed across three tertiary hospitals in Brisbane, Australia. Cases were identified using ICD‐10 codes and then individually reviewed for eligibility using prespecified inclusion and exclusion criteria. All metrics were compared over 3 months from 1 March to 31 May 2020 with two corresponding 3‐month periods in 2018 and 2019.

Results

There was a mean of 2.15 (95% CI 1.87–2.48) stroke admissions per day in the examined pandemic months compared with 2.13 (95% CI 1.85–2.45) and 2.26 (95% CI 1.97–2.59) in March to May 2018 and 2019 respectively, with no significant difference found (P = 0.81). There was also no difference in rates of intravenous thrombolysis (P = 0.82), endovascular thrombectomy (P = 0.93) and time from last known well to presentation (P = 0.54). Conversely, daily emergency department presentations (including non‐stroke presentations) significantly reduced (P < 0.0001).

Conclusions

During the early months of the COVID‐19 pandemic there was no significant reduction in stroke presentations, use of acute reperfusion therapies or delays to presentation, despite a reduction in ED presentations for any cause. Our results differ from the global experience, with possible explanations, including differences in public health messaging and healthcare infrastructure.

Ability of the Australian general public to identify common emergency medical situations: Results of an online survey of a nationally representative sample

OBJECTIVE

To investigate the Australian general public's ability to identify common medical emergencies as requiring an emergency response.

METHODS

An online survey asked participants to identify likely medical treatment pathways they would take for 17 hypothetical medical scenarios (eight emergency and nine non-emergency). The number and type of emergency scenarios participants correctly suggested warranted an emergency medical response was examined. Participants included Australian residents (aged >18 years; n = 5264) who had never worked as an Australian registered medical doctor, nurse or paramedic.

RESULTS

Most emergencies were predominately correctly classified as requiring emergency responses (e.g. Severe chest pain, 95% correct). However, non-emergency medical responses were often chosen for some emergency scenarios, such as a child suffering from a scalp haematoma (67%), potential meningococcal disease (57%), a box jellyfish sting (40%), a paracetamol overdose (37%), and mild chest pain (26%). Participants identifying as Aboriginal or Torres Strait Islander suggested a non-emergency response to emergency scenarios 40% more often compared with non-indigenous participants.

CONCLUSIONS

Educational interventions targeting specific medical symptoms may work to alleviate delayed emergency medical intervention. This research highlights a particular need for improving symptom identification and healthcare system confidence amongst Aboriginal and Torres Strait Islander populations.

Perpetrator and situational characteristics associated with security alerts in regional Australian emergency departments

Background

Workplace violence is a regular feature of emergency departments (ED) and reported to be increasing in frequency and severity. There is a paucity of data from regional EDs in Australia. The aim of this study was to identify the perpetrator and situational characteristics associated with security alerts in regional emergency departments.

Methods

This retrospective descriptive study was conducted in two regional Australian hospital EDs. All incident reports, hospital summary spreadsheets, and patient medical records associated with a security alert over a two-year period (2017 - 2019) were included. The situational and perpetrator characteristics associated with security alerts in the ED were recorded.

Results

One hundred fifty-one incidents were reported in the two-year period. Incidents most frequently occurred on late shifts and in an ED cubicle. Most incidents included multiple disciplines such as ED staff and paramedics, police and psychiatric services. One hundred twenty-five incidents had sufficient information to categorise the perpetrators. Mental and behavioural disorders (MBD) were the most frequent perpetrator characteristic present in security alerts (n = 102, 81.6%) and were associated with increased severity of incidents. MBDs other than psychoactive substance use (PSU) were associated with 59.2% (n = 74) of incidents and 66.7% (n = 18) of injuries. PSU was associated with 42.4% (n = 53) of incidents. Following PSU and MBDs other than PSU, repeat perpetrators were the next most prominent perpetrator category (24.8% n = 31) and were almost always associated with an MBD (93.5% n = 29).

Conclusions

Violence incidents in the ED are often complex, patients present with multiple issues and are managed across disciplines. Interventions need to extend from one size fits all approaches to targeting specific perpetrator groups. Since MBDs are one of the most significant perpetrator factors, interventions focussing on this characteristic are needed to address workplace violence in EDs.

A mixed methods investigation of behavioural drivers influencing Emergency Department attendance in Victoria during the 2020 COVID-19 pandemic

Objective

To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID‐19) pandemic in Victoria.

Methods

We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period.

Results

A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID‐19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID‐19 infections than they did pre‐COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre‐COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance.

Conclusion

Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID‐19 pandemic and frequently cited COVID‐19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

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 first wave of 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 the first wave of the COVID-19 pandemic 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

There was no change in the total number of ophthalmic presentations to an outer metropolitan and an increase to a rural ED during the first wave of the COVID-19 pandemic in New South Wales, Australia. A change in the type of ophthalmic presentations at these peripheral EDs suggest that a high demand for ophthalmic services remained despite the pandemic and its associated gathering and movement restrictions. A flexible healthcare delivery strategy, such as tele-ophthalmology, may optimise patient care during and after COVID-19.

OUP accepted manuscript

The purpose of this study was to determine the impact of coronavirus disease 2019 (COVID-19) on the delayed presentation of necrotising fasciitis (NF). A retrospective study was conducted of adult patients (≥16 years old) diagnosed with NF at a hospital from 2017 to 2020. A quantitative comparative analysis for the COVID-19 group and control group between 2017 and 2019. Structured interviews were conducted to examine the impact of COVID-19 on patients. There were 6 patients in the COVID-19 group and 10 patients in the control group. The COVID-19 group had a longer mean onset of symptoms till hospital presentation of 4.1 days and a longer mean operative time. The COVID-19 group was more likely to be admitted to intensive care unit. Three patients in the COVID-19 group did not survive compared to survival in the counterparts. Participant responses indicated the COVID-19 pandemic did not prevent them from presenting to ED.

Evaluation of a novel salaried medical officer position on service provision and performance at a rural health service: An exploratory mixed-methods study

OBJECTIVE

The objective of this study was to determine the impact of a new salaried medical officer position on health service provision and organisational performance.

DESIGN

Health service staff were invited to complete a survey to ascertain their overall satisfaction with the salaried medical officer position and impact on their workflow. Purposive sampling identified respondents for interviews to further explore the experiences of health service staff. Financial, administrative and quality information was extracted for analysis.

SETTING

Medium size rural health service in Victoria, Australia.

PARTICIPANTS

All general practitioner, nursing and allied health staff employed by, or who provide services to, the health service.

MAIN OUTCOME MEASURES

Satisfaction with the salaried medical officer position, ability to address patient concerns, themes from interviews, organisational performance data.

RESULTS

Forty surveys (general practitioner, nursing and allied health) were returned and 10 interviews completed. The mean rating for satisfaction with the salaried medical officer position was 8.4 out of 10. Addressing patient care concerns was rated significantly easier by nursing and allied health staff when the salaried medical officer was working. The interviews identified three broad themes: improved efficiency, increased accessibility and eliminated service gaps.

CONCLUSION

Health service staff reported that a salaried medical officer position at a rural health service improved work efficiency, increased accessibility to timely medical advice and improved quality of care, particularly patients at risk of sudden deterioration.

Trends in presentations to a private emergency department during the first and second waves of the COVID-19 pandemic in Australia

Objective The COVID-19 pandemic in Australia coincided with an early trend of reduced visits to the emergency department (ED), but to determine which patients presented less requires closer evaluation. Identifying which patient groups are presenting less frequently will provide a better understanding of health care utilisation behaviours during a pandemic and inform healthcare providers of the potential challenges in managing these groups. Methods This single-centre retrospective study examined trends in presentations in 2020 to a private, mixed paediatric and adult ED in an inner city suburb within the state of Victoria that treats both COVID-19 and non-COVID-19 patients. The 2019 dataset was used as a reference baseline for comparison. All analyses were performed using baseline characteristics and triage data. Results The total number of visits to the ED dropped from 24 775 in 2019 to 22 754 in 2020, representing an overall reduction of 8%. Significant reductions in daily presentations and admissions from the ED were observed in the months immediately following the peak of the two COVID-19 waves in the state of Victoria. Visits by those in the 0- to 17-year age group, triage categories 4 and 5 and musculoskeletal presentations were also reduced for most of 2020. Gastrointestinal/abdominal and urological/renal presentations were reduced immediately after the first COVID-19 wave, whereas infectious diseases visits were reduced during and after the second COVID-19 wave. Conclusions These findings add to the growing body of evidence regarding emergency care underutilisation during the COVID-19 pandemic. Reduced private ED presentations were observed overall and in paediatric patients, lower acuity triage categories, musculoskeletal, abdominal/gastrointestinal and urological/renal presentations during the first wave, whereas infectious disease cases were reduced during the second wave. What is known about the topic? During the first and second waves of COVID-19 in Victoria, ED visits were reduced in the public sector across all diagnostic categories and all triage categories. The effect of the COVID-19 pandemic on private ED attendance is less well known. What does this paper add? Total visits to the private ED during the first and second waves of COVID-19 were reduced across all major diagnostic categories except cardiac presentations. During this same period, visits for triage categories 4 and 5 were significantly reduced. What are the implications for practitioners? ED underutilisation during the initial two waves of the COVID-19 pandemic is apparent in both the private and public sector. Patients should be encouraged not to delay seeking urgent medical care during the pandemic.

Increased paediatric emergency mental health and suicidality presentations during COVID-19 stay at home restrictions

Objective

Anecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting.

Methods

Retrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019.

Results

We found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient).

Conclusions

Despite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic.

Effect of a waiting room communication strategy on imaging rates and awareness of public health messages for low back pain

BACKGROUND

Few studies have investigated the effects of waiting room communication strategies on health-care behavior.

OBJECTIVE

We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED).

METHODS

We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey.

RESULTS

For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages.

CONCLUSION

A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality.

TRIAL REGISTRATION

ACTRN12620000300976, 05/03/2020.

Cardiovascular and Renal Risk Factors and Complications Associated With COVID-19

The current COVID-19 pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus, represents the largest medical challenge in decades. It has exposed unexpected cardiovascular vulnerabilities at all stages of the disease (pre-infection, acute phase, and subsequent chronic phase). The major cardiometabolic drivers identified as having epidemiologic and mechanistic associations with COVID-19 are abnormal adiposity, dysglycemia, dyslipidemia, and hypertension. Hypertension is of particular interest, because components of the renin-angiotensin system (RAS), which are critically involved in the pathophysiology of hypertension, are also implicated in COVID-19. Specifically, angiotensin-converting enzyme-2 (ACE2), a multifunctional protein of the RAS, which is part of the protective axis of the RAS, is also the receptor through which SARS-CoV-2 enters host cells, causing viral infection. Cardiovascular and cardiometabolic comorbidities not only predispose people to COVID-19, but also are complications of SARS-CoV-2 infection. In addition, increasing evidence indicates that acute kidney injury is common in COVID-19, occurs early and in temporal association with respiratory failure, and is associated with poor prognosis, especially in the presence of cardiovascular risk factors. Here, we discuss cardiovascular and kidney disease in the context of COVID-19 and provide recent advances on putative pathophysiological mechanisms linking cardiovascular disease and COVID-19, focusing on the RAS and ACE2, as well as the immune system and inflammation. We provide up-to-date information on the relationships among hypertension, diabetes, and COVID-19 and emphasize the major cardiovascular diseases associated with COVID-19. We also briefly discuss emerging cardiovascular complications associated with long COVID-19, notably postural tachycardia syndrome (POTS).

Access, Use, and Patient-Reported Experiences of Emergency Care During the COVID-19 Pandemic: Population-Based Survey

Background

An increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients’ experiences of alternative management options.

Objective

The aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic.

Methods

An online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care.

Results

A total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%).

Conclusions

Telehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients’ medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

Increased number of deaths within 24 h of admission during a period of social restriction related to the COVID-19 pandemic: A retrospective service evaluation in a metropolitan palliative care unit

BACKGROUND

COVID-19 has led to implementation of wide-ranging social restriction measures with consequent impact on health care utilisation in many domains. There is little published data on the experience of palliative care services catering to a population with low case numbers of COVID-19.

AIM

This study aimed to consider the impact of COVID-19 on utilisation of inpatient palliative care in the context of low community transmission, and low numbers of cases in hospital.

DESIGN

A retrospective service evaluation examining differences in number of admissions, diagnoses, number of deaths and time from admission to death, across three discrete 8-week time periods spanning the early COVID-19 pandemic.

SETTING/PARTICIPANTS

All admissions (n = 194) to a metropolitan tertiary hospital inpatient palliative care unit in Melbourne during the study period.

RESULTS

An initial 16.9% fall in admissions was followed by a return to baseline admission numbers, with a 46.7% increase in number of deaths compared to baseline. The number of deaths within 24 h rose from 10.8% to 37.3% (p < 0.01). The number of patients with non-malignant diagnoses increased from 32.4% to 52%, and those with non-malignant diagnoses were more likely to die rapidly (p < 0.01). There were no patients with COVID-19 infection.

CONCLUSION

Increased numbers of deaths within 24 h of admission occurred on the palliative care unit despite low COVID-19 case numbers in the wider community, and in the setting of widespread social restriction measures. More research is needed examining the health-related consequences of such restrictions for individuals not infected with COVID-19.

The impact of COVID-19 restrictions on pathology service utilisation

Background

Isolation and social distancing restrictions due to COVID‐19 have the potential to impact access to healthcare services.

Aims

To assess the use of pathology services during the COVID‐19 pandemic initial restrictions.

Methods

Repeated cross‐sectional study of pathology tests utilisation during a baseline time period early in 2020 compared with pre‐lockdown and lockdown due to COVID‐19 in South Australia. The outcome measure was changed in a number of pathology tests compared to baseline period, particularly change in the number of troponin tests to determine potential impacts of lockdown on urgent care presentations.

Results

In the community setting, the ratio of a number of pathology tests pre‐lockdown and post‐lockdown versus baseline period decreased from 1.02 to 0.53 respectively. The exception was microbiology molecular tests, where the number of tests was more than three times higher in the lockdown period. The number of troponin tests in emergency departments decreased in the lockdown period compared to the baseline time period; however, there was no evidence of an association between tests result (positive vs negative) and time period (odds ratio (OR) 1.09; 95% confidence interval (CI) 0.97–1.22). There was an inverse relationship between age and time period (OR 0.995; 95% CI 0.993–0.997), indicating that fewer troponin tests were conducted in older people during the lockdown compared with the baseline period.

Conclusion

COVID‐19 restrictions had a significant impact on the use of pathology testing in both urgent and non‐urgent care settings. Further studies are needed to investigate the effect on health outcomes as a result of the COVID‐19 restrictions.

Impact of lockdowns on critical care service demand in a metropolitan hospital in Melbourne, Australia

OBJECTIVE

There is a growing recognition of the impact of lockdowns on non-COVID-19 demand for critical care services. While a reduction in demand has been postulated, there remains a paucity of quantitative data on the extent and nature of this reduction. The present study aims to quantify the impact of lockdown on critical care services, namely ED, intensive care unit (ICU), medical emergency team (MET) and emergency theatre (ET) demand, during the lockdown in Victoria, Australia.

METHODS

This is a single-centred, retrospective observational study on critical service demand, comparing activity levels during the lockdown (31 March to 27 October 2020) with the matched time period from 1 year prior.

RESULTS

There was a reduction in presentations to ED (27.2%), MET calls (27.4%), ICU patient episodes (14.5%) and ET bookings (5.8%). There was an unexpected increase in ICU admissions for metabolic diagnoses, comprising drug overdoses and diabetic ketoacidosis, and a reduction in respiratory ICU admissions. There was a reduction across all ED triage categories, which included triage 1 and 2 patients, indicating a reduction even in life-threatening and emergency presentations.

CONCLUSION

Lockdowns lead to a significant reduction in ICU, MET call and ED demand, and to a lesser extent ET demand. This pattern should be considered in surge capacity and workforce redeployment planning. There are also impacts on public health epidemiology, with potential adverse consequences on mental health and chronic disease management. Further research on the impact of lockdowns on long-term disease outcomes is needed.

COVID-19 had no impact on emergency urological admissions at an Australian tertiary hospital

BACKGROUNDS

The COVID-19 pandemic is an unprecedented threat to health and healthcare systems. There is no published data on the impact on urological presentations in Australia.

METHODS

A retrospective analysis of all admissions under the urology service at Liverpool Hospital, Australia from February 1st to April 30th for 2020 and the previous 5 years.

RESULTS

There was a total of 397 admissions in 2020 and 438 in 2019. The mean age, proportion of male, and mean length of stay were similar. In 2020, there were 229 emergency admissions. Over the same period during the previous 5 years, there were between 195 and 218 emergency admissions. In 2019, there were 220 planned admissions and 168 in 2020. Between 2019 and 2020, there was no significant difference in the proportion of patients with admission longer than 10 days (P = 0.602), requiring intensive care unit admission (P = 0.708) or inpatient operative management (P = 0.171). Among the emergency admissions, the mean Charlson Comorbidity Index was significantly lower in 2020 compared to 2019 (P = 0.009).

CONCLUSIONS

Despite the pervasive fear of the COVID-19 pandemic and multiple, substantial alterations to hospital systems, structures and elective operating restrictions, no significant difference in numbers or acuity of emergency admissions were observed. Due to limitations in elective operating, there was an expected reduction in planned admissions. Our findings are in contrast to multiple recent studies and may be the result of our patient demographic where health-seeking behaviours appear to have not been significantly influenced by the pandemic.

The Impact of the COVID-19 Pandemic on Demand for Emergency Ambulances in Victoria, Australia

Objective: Relatively little has been reported about the impact of COVID-19 restrictions on emergency ambulance services. We describe the influence of the COVID-19 pandemic on the emergency ambulance system in Victoria, Australia.Methods: We performed an interrupted time series analysis of consecutive calls for ambulance from January 2018 to February 2021, including two waves of COVID-19. The COVID-19 lockdown period included seven months of stay-at-home restrictions (16/03/2020-18/10/2020). Nineteen weeks of post-lockdown data were included (19/10/2020-28/02/2021).Results: In total, 2,356,326 consecutive calls were included. COVID-19 lockdown was associated with an absolute reduction of 64,991 calls (almost 2,100 calls/week). According to time series analysis, lockdown was associated with a 12.6% reduction in weekly calls (IRR = 0.874 [95% CI 0.811, 0.941]), however no change in long-term trend (IRR = 1.000 [95% CI 0.996, 1.003]). During lockdown, the long-term trend of attendances to patients with suspected acute coronary syndromes (ACS, IRR = 1.006 [95% CI 1.004, 1.009]) and mental health-related issues (IRR = 1.005 [95% CI 1.002, 1.008]) increased. After lockdown, the call volume was 5.6% below pre-COVID-19 predictions (IRR = 0.944 [95% CI 0.909, 0.980]), however attendances for suspected ACS were higher than predicted (IRR = 1.069 [95% CI 1.009, 1.132]). Ambulance response times deteriorated, and total case times were longer than prior to the pandemic, driven predominantly by extended hospital transfer times.Conclusion: The COVID-19 pandemic had a dramatic impact on the emergency ambulance system. Despite lower call volumes post-lockdown than predicted, we observed deteriorating ambulance response times, extended case times and hospital delays. The pattern of attendance to patients with suspected ACS potentially highlights the collateral burden of delaying treatment for urgent conditions.

Effect of COVID-19 on management of patients with low back pain in the emergency department

Background

Patients presenting to Emergency Department (ED) with non-specific low back pain can receive more unnecessary, intensive and costly care than is recommended. The COVID-19 pandemic has provided an unprecedented opportunity to examine how health systems prioritise necessary care that provides clear benefits to patients. The purpose of this study was to examine the impact of COVID-19 on care of low back pain in the ED.

Methods

We performed a retrospective analysis of electronic medical record data on care for low back pain from three public hospitals in Sydney. We included patients diagnosed with spinal conditions who presented between March and May in 2019 and in 2020. Outcomes were the total number of patients presenting with spinal conditions to ED, the proportion diagnosed with non-specific low back pain, and the proportion receiving potentially unnecessary aspects of care (ambulance use, imaging, opioids, hospital admissions). We calculated relative risk with 95% CIs and examined plots with locally weighted smoothed curves.

Results

Presentations for spinal conditions over a three-month period to three EDs reduced from 694 in 2019 to 475 in 2020 (31% reduction, 95% CI = 26%–37%). The proportion of patients diagnosed with non-specific low back pain (83% in 2019 vs 86% in 2020), or receiving potentially unnecessary care were similar in 2019 and 2020 (Imaging = 25% vs 25%; Opioids = 54% vs 56%; Admitted = 18% vs 20%; pathology test = 24% vs 23%). The proportion of patients arriving by ambulance was higher during the pandemic; 29% in 2019 vs 41% in 2020 (RR = 1.39, 95% CI = 1.19–1.63).

Conclusions

ED presentations for low back pain associated with spinal conditions decreased substantially during the COVID-19 pandemic. Use of potentially unnecessary aspects of care did not change or increased during the pandemic.

Emergency department presentations in the Southern District of New Zealand during the 2020 COVID-19 pandemic lockdown

OBJECTIVE

To assess changes in presentations to EDs during the COVID-19 pandemic lockdown in the Southern Region of New Zealand.

METHODS

We conducted a retrospective audit of patients attending EDs in the Southern District Health Board (SDHB), from 1 March to 13 May 2020. We made comparisons with attendances during the same period in 2019. The 2020 study period included 'pre-lockdown' (1 March-25 March), 'level 4 (strict) lockdown' (26 March-27 April) and 'level 3 (eased) lockdown' (28 April-13 May).

RESULTS

Patient volumes reduced in all SDHB EDs during levels 4 and 3, mostly representing a loss of low acuity patients (Australasian Triage Scale 3, 4 and 5), although high-acuity presentations also declined. Average patient age increased by 5 years; however, the proportions of sexes and ethnicities did not change. Presentations of cerebrovascular accidents and appendicitis did not change significantly. Trauma, mental health, acute coronary syndrome and infectious respiratory presentations decreased significantly during level 4, and infectious respiratory presentations decreased further in level 3.

CONCLUSIONS

Within the SDHB, patient volumes reduced during levels 4 and 3 of our lockdown, with reduced low-acuity presentations. High-acuity patient numbers also declined. Trauma, mental health, alcohol-related, infectious respiratory and acute coronary syndrome presentations declined while cerebrovascular accident and appendicitis numbers showed little to no change.

Beware of the bicycle! An increase in paediatric bicycle related injuries during the COVID-19 period in Western Australia

Background

In Western Australia, the media has reported on an increase in the purchasing, repairs and use of bicycles during the COVID‐19 period. The study aimed to investigate for a relationship in bicycle related injuries in the paediatric population during the time of COVID‐19 restrictions.

Methods

A retrospective study of the incident of motorized and non‐motorized bicycle related injuries and trauma presentations during the COVID‐19 ‘shutdown’ period from March to June 2020. Data were collected from the Emergency Department Information System, discharge summaries, operation and radiology reports. The data presented is from Perth Children's Hospital, the only tertiary paediatric hospital and the only referral centre for childhood trauma in the state of Western Australia. Participants were children aged 15 years and younger attending the emergency department (ED) at Perth Children's Hospital during the designated time period. The primary outcomes included total ED presentations, bicycle related presentations and bicycle related admissions during the COVID‐19 period.

Results

Bicycle related presentations to the ED increased by 42.7% over the COVID‐19 period from 1.4% to 3.0% of all children attending the ED. Children admitted to the hospital with bicycle related injuries or trauma increased by 48.7% from 76 to 113 children in comparison to the same period in 2019.

Conclusion

During the period of COVID‐19 restrictions, paediatric ED presentations decreased dramatically, but bicycle related injuries and trauma increased substantially. Safety equipment including helmets and protective gear should be worn for all children riding bicycles, and social distancing should be maintained.

University students and study habits

OBJECTIVES

The objective of this study was to understand the variables or study habits that inform study in undergraduate and postgraduate students attending Trinity College Dublin.

METHODS

A descriptive, cross-sectional anonymous online survey was used to gather data to explore student study habits. Survey 1 was completed by participants in April 2019 and survey 2 was completed by participants in April 2020, during the COVID-19 restrictions.

RESULTS

A total of 1557 participants completed survey 1 in 2019, and 1793 participants completed survey 2 in 2020. In both surveys a majority reported using caffeine, library study, sleep pattern adjustment and excercise to aid academic performance. Survey 2 participants reported COVID-19 resulted in increased difficulty studying (91%). In particular loss of structure and routine was negatively impacted by the pandemic (92%), and increased feelings of stress were reported (75%).

CONCLUSIONS

Our study suggests a potential role of the college environment as a target for the implementation of interventions to promote student learning, healthy study habits and well-being. The global pandemic has resulted in additional challenging demands for universities to serve an essential role in supporting college students study habits.

Impact of the COVID-19 pandemic on South Australia's emergency departments: evidence from two lockdowns

Objective This study assessed the impact of the COVID-19 pandemic on emergency departments (EDs) in South Australia, measured by changes in the number and casemix of patients in the system over time. Methods Data from the South Australia Emergency Department Dashboard, updated every 30min, were analysed for the period 4 October-21 December 2020. The Dashboard reports live counts of the number and type of patients in each of the six adult metropolitan public EDs in Adelaide, South Australia. Results There was a significant difference in the mean daily average occupied ED capacity before and during two distinct increases in COVID-19 cases in South Australia. An increase in COVID-19 cases coincided with a decrease in patients in EDs (Pearson's r =-0.93 and -0.67; P Conclusions During the two periods of COVID-19 case growth in South Australia, there was a significant drop in the number of patients presenting to the major public EDs and a change in the casemix of patients over time. What is known about the topic? EDs in Australia often operate at or over capacity, with frequent reports of ambulance ramping, access block and long waiting times. There have been reports internationally of significant declines in ED presentations throughout the COVID-19 pandemic. What does this paper add? This paper uses a novel publicly available data source that is available in real time to contribute a new perspective from South Australia, which has experienced two distinct periods of strict restrictions and lockdown. The research showed that the number of mental health presentations remained consistently high, despite a significant overall decline in ED occupancy. What are the implications for practitioners? This study demonstrates that South Australians are accessing emergency medical treatment differently in response to the COVID-19 pandemic. In the context of an overall decline in presentation numbers, the number of mental health-related presentations has not changed significantly, suggesting that this trend should be closely monitored. The findings corroborate the national concern that unwell people have avoided accessing emergency medical care during the pandemic, leading to worse outcomes and increased need for healthcare resources at a later date. It will be important to monitor and quickly detect further changes in ED usage using real-time data as the pandemic evolves, as well as in any future significant health crises.