Evaluating the effect of COVID-19 incidence on Emergency Departments admissions. Results from a retrospective study in Central Italy during the first year of pandemic

Introduction

The COVID-19 pandemic has had a major impact on the Healthcare System, changing the patterns of Emergency Department access. In fact, accesses for trauma and less severe cases decreased significantly. This decline has generally been attributed to both the effects of the lockdown, imposed by the government, and the fear of being infected by SARS-CoV-2 in the hospital. However, the correlation between these elements is not yet clear, since the accesses to the Emergency Department did not increase either at the end of the lockdown or in the summer when the epidemiological situation was more favorable. Aim: To evaluate the association between trends of Emergency Department accesses and COVID-19 incidence in 2020.

Methods

Data on Emergency Department accesses, by month and severity triage code, from 14 hospitals in southeastern Tuscany (Italy) were obtained from hospitals' data warehouse. Official data on new cases of COVID-19 infection were used to calculate incidence. Hospitals were classified into 4 categories. Differences in Emergency Department access by month, triage code, and hospital type were investigated using Kruskal-Wallis analysis. Association between Emergency Department accesses and COVID-19 incidence was evaluated using a random-effect panel data analysis, adjusting for hospital type and triage code.

Results

The trend of 268,072 Emergency Department accesses decreases substantially at the first pandemic peak; thereafter, it increased and decreased again until the minimum peak in November 2020. COVID-19 incidence appeared to be overlapping with an inverse direction. Monthly differences were significant (p<0.01) except for most severe codes. There was a significant inverse association between Emergency Department accesses and COVID-19 incidence (Coef. =-0.074, p<0.001) except for most severe cases (triage code 1: Coef. =-0.028, p=0.154).

Conclusion

Emergency Department admissions trend followed the COVID-19 incidence, except for the most severe cases. Fear of infection seems to discourage patients from accessing Emergency Department for illnesses perceived as not serious.

Emergency Department: Analysis of Patient Flow and Length of Stay Variations

Background

Crowding in Emergency Departments(ED)is a severe public health issue.Length of stay(LOS)is not a direct measure of crowding,but it is an essential indicator for monitoring emergency care quality.LOS in ED can be associated with delays in treatment,decreased patient satisfaction and adverse outcomes.The aim of this study is to analyze ED LOS in the Teaching Hospital of Siena for further strategies.

Methods

A retrospective observational study was conducted between January 1,2019, and December 31,2021.To manage admissions and discharges, all patients’ data admitted to ED of the University Hospital of Siena were accessed by Aurora,the IT system.In addition,a descriptive analysis was performed, collecting the following variables:sex,age,arrival mode,ED visit reasons,triage code,discharge mode,hospital admission area and LOS(cut-off>8hours).The analysis was carried out using STATA 17:variables were analyzed with ANOVA test.

Results

Our sample consisted of 152.393 patients (F49.47% M50.53%),and the average age was 50.51(SD ± 26.07).During the years total ED visits decreased:65.426(2019);40.318(2020); 46.649(2021),and there was a significant increase (p < 0.001) of patients with LOS>8 hours:13.96%(2019); 21.51%(2020); 23.10%(2021).In the years 2019,2020 and 2021, admissions of patients with LOS>8 hours were respectively: 25.92%; 43.95% and 37.09%, with the following percentage in medical areas:69.96% in 2019;70.51% in 2020;64.55% in 2021.A progressive increase of admissions in COVID area resulted since 2020(2.23%-2020;6.07%-2021).

Conclusions

The spread of COVID-19 and the containment measures,such as lockdown,caused a significant decrease in ED access.The increase LOS>8h could be primarily due to the time needed to perform laboratory investigations for the search for SARS-CoV-2 but also to the overflow of SARS-CoV-2-infected patients rapidly saturating the ED boxes and hospital bed capacity,with the need sometimes to dedicate other medical areas to manage COVID patients.

Key messages

• ED-LOS is a proxy indicator to monitor emergency care quality.

• Further investigations should be performed to analyze the leading causes of ED LOS increase during the pandemic period.

COVID-19 incidence on Emergency Departments accesses. Health need and fear of infection, what wins?

Introduction

The COVID-19 pandemic has changed the patterns of access to the Emergency Department (ED), but it is unclear whether this change was due to COVID-19 incidence or the lockdown imposed by law.

Aim

To evaluate the association between trends of ED accesses and COVID-19 incidence in the period 1 January - 31 December 2020.

Material and methods

The data of accesses to the ED per month and severity triage code of 14 hospitals in the Southeast Tuscany (Italy, Provinces of Siena, Arezzo, Grosseto) were obtained from hospitals data warehouses. Data on new cases of COVID-19 infection (obtained by the Ministry of Health) for the 3 provinces were used to calculate the incidence of infection. Hospitals were classified in 4 categories based on beds number, medical specialties offered, services provided. Differences in ED accesses by month, triage code and hospital type were investigated by a Kruskal-Wallis analysis of variance. Association between ED accesses and COVID-19 incidence was evaluated using a random effect panel data analysis adjusting for hospital type and triage code.

Results

A total of 268,072 ED accesses have been studied. Their trends saw a strong decrease in correspondence of the first pandemic peak, subsequently they are increased and then decreased again until the minimum peak in November 2020. COVID-19 incidence appeared to overlap, but in the reverse direction, with ED admissions trends. Monthly differences of the ED accesses were significant (p &lt; 0.01) except for most severity code. There is a statistically significant inverse association between ED accesses and COVID-19 incidence (Coef. = -0.074, p &lt; 0.001) except for most severe cases (triage code 1: Coef. = -0.028, p = 0.154).

Conclusions

ED admissions trends followed the COVID-19 incidence independently from the period of lockdown except for the most severe cases. The fear to contract the infection seemed to discourage patients to access ED for diseases that were perceived as not serious.

Key messages

• The pandemic has changed the lifestyle of people worldwide, modifying even the perception that the patient has of own state of health and their access to Emergency Department.

• The decrease in accesses involved less severe cases. Reflect on both the adequacy of accesses in the pre-pandemic period and on what is the best setting to manage these cases in the pandemic period.

A Literature Systematic Review with Meta-Analysis of Symptoms Prevalence in Covid-19: the Relevance of Olfactory Symptoms in Infection Not Requiring Hospitalization

PURPOSE OF REVIEW

To investigate the association between the olfactory dysfunction and the more typical symptoms (fever, cough, dyspnoea) within the Sars-CoV-2 infection (COVID-19) in hospitalized and non-hospitalized patients.

RECENT FINDINGS

PubMed, Scopus and Web of Science databases were reviewed from May 5, 2020, to June 1, 2020. Inclusion criteria included English, French, German, Spanish or Italian language studies containing original data related to COVID19, anosmia, fever, cough, and dyspnoea, in both hospital and non-hospital settings. Two investigators independently reviewed all manuscripts and performed quality assessment and quantitative meta-analysis using validated tools. A third author arbitrated full-text disagreements. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 11 of 135 studies fulfilled eligibility. Anosmia was estimated less prevalent than fever and cough (respectively rate difference = - 0.316, 95% CI: - 0.574 to - 0.058, Z = - 2.404, p < 0.016, k = 11 and rate difference = - 0.249, 95% CI: - 0.402 to - 0.096, Z = - 3.185, p < 0.001, k = 11); the analysis between anosmia and dyspnoea was not significant (rate difference = - 0.008, 95% CI: - 0.166 to 0.150, Z = - 0.099, p < 0.921, k = 8). The typical symptoms were significantly more frequent than anosmia in hospitalized more critical patients than in non-hospitalized ones (respectively [Q(1) = 50.638 p < 0.000, Q(1) = 52.520 p < 0.000, Q(1) = 100.734 p < 0.000).

SUMMARY

Patient with new onset olfactory dysfunction should be investigated for COVID-19. Anosmia is more frequent in non-hospitalized COVID-19 patients than in hospitalized ones.

Clinical risk management in High-Security Forensic Psychiatry Residences. Protecting patients and health professionals: perspectives and critical issues of the Law 81/2014

The Italian Law n. 9/2012 provided the Italian Regions with a new decisional role by demanding the management/rehabilitation of prisoners judged as partially/fully mentally ill to care and protection delivered by the psychiatric services of the Regional Health Service. Healthcare has to be guaranteed by the so-called High-Security Forensic Psychiatry Residences (Italian: Residenze per l'Esecuzione delle Misure di Sicurezza: REMS) and by community mental health centres. Ensuring patients' and professionals' health and safety is a complex issue which requires effective strategies to cope with several structural, technological, and organisational problems. The present paper summarises the historical evolution of the Italian laws towards the development of the High-Security Forensic Psychiatry Residences in Italy, focusing specifically on the Tuscany Region situation. The paper also presents the key issues emerging after the implementation of the Law 81/2014 which complemented the Law 9/2012. Since these reforms included the need for assessing to what extent the patient may be considered as a danger to society and for ensuring the safety of National Health Service (NHS) professionals, they underscored the importance of a preventive use of specific clinical governance tools aimed to reduce risk of adverse events. The present work has the strength of proposing a new, evidence-based scientific approach to the implementation of assessment and care pathways in High-Security Forensic Psychiatry Residences.

A queueing theory based model for business continuity in hospitals

Clinical activities can be seen as results of precise and defined events' succession where every single phase is characterized by a waiting time which includes working duration and possible delay. Technology makes part of this process. For a proper business continuity management, planning the minimum number of devices according to the working load only is not enough. A risk analysis on the whole process should be carried out in order to define which interventions and extra purchase have to be made. Markov models and reliability engineering approaches can be used for evaluating the possible interventions and to protect the whole system from technology failures. The following paper reports a case study on the application of the proposed integrated model, including risk analysis approach and queuing theory model, for defining the proper number of device which are essential to guarantee medical activity and comply the business continuity management requirements in hospitals.