Changes in Acute ED Visits by Race/Ethnicity During the Early COVID-19 Pandemic.

Emergency department (ED) visits for conditions unrelated to the Coronavirus Disease 2019 (COVID-19) pandemic decreased during the early pandemic, raising concerns about critically ill patients forgoing care and increasing their risk of adverse outcomes. It is unclear if Hispanic and Black adults, who have a high prevalence of chronic conditions, sought medical assistance for acute emergencies during this time. This study used 2018-2020 ED visit data from the largest safety net hospital in Los Angeles County to estimate ED visit differences for cardiac emergencies, diabetic complications, and strokes, during the first societal lockdown among Black and Hispanic patients using time series analyses. Emergency department visits were lower than the expected levels during the first societal lockdown. However, after the lockdown ended, Black patients experienced a rebound in ED visits while visits for Hispanics remained depressed. Future research could identify barriers Hispanics experienced that contributed to prolonged ED avoidance.

Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time-Series Analysis.

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential "rebound" in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent "rebound" period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no "rebound" above expected values in psychiatric ED visits overall (coef = - 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric "pandemic" of urgent visits.

COVID-19 case counts and COVID-19 related Emergency Department visits: differences by immigration status, March-December 2020.

BACKGROUND: Undocumented immigrants face barriers to health care access, which may have been exacerbated during the early days of the COVID-19 pandemic. We test whether undocumented immigrants in Los Angeles County accessed COVID-19 related medical care by examining their Emergency Department (ED) patterns through high and low periods of COVID-19 infection. If undocumented immigrants were underutilizing or foregoing health care, we expect null or weaker associations between COVID-19 cases and COVID-19 related ED visits relative to Medi-Cal patients. METHODS: We analyzed all ED visits to the Los Angeles County + University of Southern California (LAC + USC) Medical Center between March - December 2020 (n = 85,387). We conducted logistic regressions with Los Angeles County weekly COVID-19 case counts as our main independent variable and an interaction between case counts and immigration status, stratified by age (over and under 65 years). RESULTS: We found that undocumented immigrants under 65 years old had a higher odds for a COVID-19 related ED visit compared to Medi-Cal patients and that both undocumented and Medi-Cal patients had higher odds of a COVID-19 related ED visit as COVID-19 cases in Los Angeles County increased. For patients over 65 years, Medi-Cal patients actually had a weaker association between ED visits and county COVID-19 counts; as COVID-19 case counts rose, the odds of a COVID-19 related ED visit increased for the undocumented patients. CONCLUSION: While the overall likelihood of undocumented patients having a COVID-19 related ED visit varies compared to Medi-Cal patients - for younger patients, the odds is higher; for older patients, the odds is lower - it does not appear that undocumented patients underutilized the ED during the early COVID-19 pandemic relative to Medi-Cal patients. The ED may be a viable source of contact for this high-risk population for future outreach.

Emergency Department Utilization Among Undocumented Latino Patients During the COVID-19 Pandemic.

OBJECTIVE: To determine whether Latino undocumented immigrants had a steeper decline in Emergency Department (ED) utilization compared to Latino Medi-Cal patients in a Los Angeles safety-net hospital, March 13, 2020, to May 8, 2020. STUDY DESIGN: The data were extracted from patient medical records for ED visits at LAC + USC Medical Center from January 2018 to September 2020. We analyzed weekly ED encounters among undocumented Latino patients in the nine-week period after COVID was declared a national emergency. We applied time-series routines to identify and remove autocorrelation in ED encounters before examining its relation with the COVID-19 pandemic. We included Latino patients 18 years of age and older who were either on restricted or full-scope Medi-Cal (n = 230,195). RESULTS: All low-income Latino patients, regardless of immigration status, experienced a significant decline in ED utilization during the first nine weeks of the pandemic. Undocumented patients, however, experienced an even steeper decline. ED visits for this group fall below expected levels between March 13, 2020, and May 8, 2020 (coef. = - 38.67; 95% CI = - 71.71, - 5.63). When applied to the weekly mean of ED visits, this translates to a 10% reduction below expected levels in ED visits during this time period. CONCLUSION: Undocumented immigrants' health care utilization was influenced by external events that occurred early in the pandemic, such as strict stay-at-home orders and the public charge rule change. Health care institutions and local policy efforts could work to ensure that hospitals are safer spaces for undocumented immigrants to receive care without immigration concerns.

A dynamic, D-dimer-based thromboprophylaxis strategy in patients with COVID-19

Background While Coronavirus disease 2019 (COVID-19) is associated with increased risk for venous thromboembolism (VTE) during hospitalization despite prophylactic anticoagulation, there is a lack of evidence-based guidelines for dose escalation of anticoagulation for patients hospitalized with COVID-19. Methods This single-center retrospective cohort study was part of a quality improvement program evaluating safety and efficacy of anticoagulation protocols at our large, metropolitan public hospital. We implemented a D-dimer-based guideline for dosing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) in COVID-19 hospitalized patients that allowed for up-titration from standard prophylactic dosing to escalated prophylactic dosing or therapeutic dosing based on patient risk and presence of known or highly suspected VTE. Primary endpoints were International Society on Thrombosis and Haemostasis (ISTH)-defined major and clinically relevant non-major bleeding (CRNMB) events and in-hospital survival. Findings Among 262 COVID-19-infected patients hospitalized between March 15th and June 15th, 2020, 125 (73.1%) were male. Highest anticoagulation dose was: 65.3% prophylactic, 13.4% escalated prophylactic, 21.4% therapeutic. The dose was uptitrated in 83 (31.6%) patients. Bleeding events were comparable between the therapeutic (12.5%) and escalated prophylactic groups (11.4%), but significantly higher than in the prophylactic group (1.2%). In-hospital survival at 28 days was superior among patients whose anticoagulation was uptitrated to either escalated prophylactic or therapeutic (77.6%), compared to those receiving fixed prophylactic (56.7%) or fixed therapeutic (26.7%) dosing (p = 0.001). Conclusion A dynamic, D-dimer based dose escalation of anticoagulation for hospitalized patients with COVID-19 may improve in-hospital mortality without increasing fatal bleeding.