Emergency department visits continue to lag

People continue to avoid the emergency department, particularly for less-urgent care, a trend that may stick beyond the COVID-19 pandemic, experts forecast.

ED volumes have been the slowest to rebound compared with total admissions and surgeries across hospitals, many of which are still reporting a decline in June year-over-year results—about 20%—largely due to fewer lower-acuity visits.

If less-complex care is redirected to more appropriate, cost-effective settings, COVID-19 has unintentionally solved a vexing problem: keeping non-urgent cases out of the ED. That could prove important as hospital executives redesign their EDs to prevent COVID-19 transmissions.

But if care is being forgone altogether, physicians are concerned that patients will become sicker and outcomes will deteriorate.

ED admissions are also an important referral source for hospitals. If health systems do not adequately prepare alternative care pathways, they will likely lose market share.

”We saw people, with COVID-19 and without, coming into the ED who were very ill,” said Dr. Vik Reddy, chief medical officer of Wellstar Kennestone Hospital and Wellstar Windy Hill Hospital in the Atlanta area, noting that some patients delayed care for a couple of days after suffering a heart attack or appendicitis, which could lead to a longer recovery and worse outcomes. “The good news is that we’re seeing that trend reverse this time around. It was scary in March when we knew that people weren’t coming into the ED for heart attacks.”

During the pandemic’s  initial peak in April, ED visits across hospitals nationwide declined 42% from a mean of 2.1 million per week to 1.2 million, according to an analysis by the National Syndromic Surveillance Program. In the 10 weeks following declaration of the COVID-19 national emergency, ED visits fell 23% for heart attacks, 20% for strokes and 10% for hyperglycemic crises, NSSP data show.

As of the end of May, there were 26% fewer ED visits compared with the same period in 2019.

The national figures align with Georgia-based Wellstar Health System, which recently completed a 263,000-square-foot emergency department for its Kennestone Hospital in Marietta. Wellstar’s ED visits were down nearly 50% in April compared with its historical volumes, and they continue to lag around 20% as low-acuity cases have dropped off, Reddy said.

Wellstar has expanded the hours of its pediatrics and urgent-care facilities as well as its reach via telehealth, which explains some of the decline. That also allowed the system to retain patients and downstream care. The rest may be explained by individuals’ fear of being exposed to COVID-19 in the ED, financial distress, extended wait times, or a sense of civic responsibility to avoid using healthcare services that others may need more.

Looking at utilization across care settings, it seems patients are likely eschewing lower-acuity care, said Christopher Kerns, vice president of executive insights at the Advisory Board. About 45% of patients intend to skip their annual physical this year, according to a May PricewaterhouseCoopers survey of 2,500 consumers.

Nearly 20% said they are likely to avoid the ED despite showing signs of a heart attack or appendicitis and 34% say they are likely to avoid the ED even if they have a cut that may require stitches, a June Optum survey of 7,000 consumers found. Providers are expecting cases to be more severe in the second half of the year, which will require more complex and expensive care, Kerns said.

Health system strategic planners expect unavoidable ED utilization to recover to 96% of its pre-pandemic levels this year and avoidable ED utilization to recover to 93%, according to an Advisory Board survey sent out in May.

Franklin, Tenn.-based Community Health Systems is currently seeing its highest number of COVID-19 admissions in Texas and Florida as it manages varying degrees of surge in Mississippi and Alabama. The 97-hospital investor-owned chain’s ED visits were still 20% off as of June but had improved from a 45% decline in April.

Most of that was due to a decline in lower-acuity cases; higher-acuity cases have largely recovered, executives said during a second-quarter earnings call.

But hospitals and systems that haven’t received federal aid will likely see revenue declines over the short term, said Mark Armstrong, a shareholder at consultancy LBMC. “They will notice a financial impact until they adjust to the new reality,” he said, adding that hospitals may have to adjust ED staffing levels and other resources.

In Fort Worth, Texas, there was a 55% increase in heart attacks from May 2019 to May 2020, but 911 calls were down 21%, according to data from Medstar, an emergency medical services company. Of those patients, the number pronounced dead on the scene was up 65% over that period.

“Many people were afraid to call 911 and consequently many suffered serious cardiac problems, strokes and even death,” said Stephen Love, CEO of the Dallas-Fort Worth Hospital Council, adding that the council worked with healthcare providers to raise awareness that it was safe to go to the ED. “Now, many of our hospitals are reporting emergency department volume normalizing in comparison to last year.”

Armstrong is hopeful that fewer people will be coming to the ED with other illnesses like the flu as they are being more cautious, washing their hands more, social distancing and wearing masks. “It stands to reason that those precautions have mitigated other illnesses they would’ve gotten,” he said.