Behavioural drivers influencing emergency department attendance in Victoria during the 2020 COVID-19 pandemic: A mixed methods investigation.

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.

Preparing for reopening: An emergency care perspective.

Australia is rapidly moving towards 'living with COVID-19', with relaxation of some public health measures. The number of severe cases of COVID-19 may be mitigated by vaccination, but 'living with COVID-19' will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co-ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system.

Outcomes for emergency department patients with suspected and confirmed COVID-19: An analysis of the Australian experience in 2020 (COVED-5).

OBJECTIVE: The aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID-19 during 2020, and to determine the predictors of in-hospital death for SARS-CoV-2 positive patients. METHODS: This analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID-19 and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in-hospital mortality. RESULTS: Among 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS-CoV-2. During the 'second wave' from 1 July to 30 September 2020, 26 (6%) of 406 SARS-CoV-2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS-CoV-2 negative patients (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.3-5.2, P < 0.001), and 41 (10%) SARS-CoV-2 positive patients died in hospital compared to 312 (3%) SARS-CoV-2 negative patients (OR 3.2; 95% CI 2.2-4.4, P = 0.001). For SARS-CoV-2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1; 95% CI 1.1-1.1, P < 0.001), higher triage category (OR 3.5; 95% CI 1.3-9.4, P = 0.012), obesity (OR 4.2; 95% CI 1.2-14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2; 95% CI 1.8-36.7, P = 0.006). CONCLUSIONS: ED patients who tested positive for SARS-CoV-2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.

COVID-19 and emergency care for adults experiencing homelessness.

Homeless individuals face many barriers to accessing healthcare, and EDs are often their primary entry point to the healthcare system. The COVID-19 pandemic has the potential to exacerbate existing social inequities and health disparities, including barriers to accessing social services and healthcare. Addressing the complex social and chronic health issues associated with homelessness can be challenging within the acute care environment. This perspective reflects upon the delivery of emergency healthcare to patients experiencing homelessness, and highlights strategies for optimising health outcomes during and beyond the pandemic.

Epidemiology and clinical features of emergency department patients with suspected and confirmed COVID-19: A multisite report from the COVID-19 Emergency Department Quality Improvement Project for July 2020 (COVED-3).

OBJECTIVE: The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID-19. METHODS: The COVID-19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from eight sites across Victoria and Tasmania for July 2020 (during Australia's 'second wave'). All adult patients who met criteria for 'suspected COVID-19' and underwent testing for SARS-CoV-2 in the ED were eligible for inclusion. Study outcomes included a positive SARS-CoV-2 test result and mechanical ventilation. RESULTS: In the period 1 July to 31 July 2020, there were 30 378 presentations to the participating EDs and 2917 (9.6%; 95% confidence interval 9.3-9.9) underwent testing for SARS-CoV-2. Of these, 50 (2%) patients returned a positive result. Among positive cases, two (4%) received mechanical ventilation during their hospital admission compared to 45 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.3; P = 0.47). Two (4%) SARS-CoV-2 positive patients died in hospital compared to 46 (2%) of the SARS-CoV-2 negative patients (odds ratio 1.7, 95% confidence interval 0.4-7.1; P = 0.49). Strong clinical predictors of a positive SARS-CoV-2 result included self-reported fever, non-smoking status, bilateral infiltrates on chest X-ray and absence of a leucocytosis on first ED blood tests (P < 0.05). CONCLUSION: In this prospective multi-site study from July 2020, a substantial proportion of ED patients required SARS-CoV-2 testing, isolation and enhanced infection prevention and control precautions. Presence of SARS-CoV-2 on nasopharyngeal swab was not associated with death or mechanical ventilation.

Presentations of stroke and acute myocardial infarction in the first 28 days following the introduction of State of Emergency restrictions for COVID-19.

OBJECTIVES: To determine if Victorian State of Emergency (SOE) measures to combat COVID-19 were associated with delayed presentations or management of acute stroke and acute myocardial infarction (AMI). METHODS: This was a retrospective, pre- and post-implementation study using data from an adult, tertiary cardiology and neurosciences centre with 24-h capacity for endovascular procedures. All primary presentations with acute stroke or AMI during the first 28 days of stage 2 and stage 3 SOE restrictions (26 March to 23 April 2020) were compared to an equivalent period without restrictions (26 March to 23 April 2019). The primary outcome variable was time from onset of symptoms to ED presentation. RESULTS: There were 52 (1.6% of all ED presentations) patients who met inclusion criteria during the SOE period and 57 (1.0%) patients in the comparator period. Patients were equally matched for demographics, disease severity and prior history of stroke or AMI. Median time from symptom onset to presentation was 227 (93-1183) min during the SOE period and 342 (119-1220) min during the comparator period (P = 0.24). Among eligible patients with ischaemic stroke or ST-elevation AMI, median time to primary reperfusion intervention was 65 (37-78) min during SOE and 44 (39-60) min in the comparator period (P = 0.54). There were no differences in mortality at hospital discharge (9.6% vs 10.5%) and hospital length of stay (5.4 vs 4.3 days). CONCLUSIONS: In the first 28 days, SOE measures to combat COVID-19 were not associated with delays in presentation or life-saving interventions for patients with acute stroke and AMI.

Impact of patient isolation on emergency department length of stay: A retrospective cohort study using the Registry for Emergency Care.

OBJECTIVE: The number of patients with suspected COVID-19 presenting to Australian EDs continues to impose a burden on healthcare services. Isolation is an important aspect of infection prevention and control, but has been associated with undesirable consequences among hospital inpatients. The aim of the present study was to determine if isolation is associated with an increased length of stay (LOS) in the ED. METHODS: The Registry for Emergency Care Project is a prospective cohort study with a series of nested sub-studies. The present study was a retrospective analysis of adult patients allocated an Australasian Triage Scale category of 1 or 2 who presented to a tertiary ED between 18 and 31 May 2020. The primary outcome was ED LOS. Regression methods were used to determine the independent association between ED isolation and LOS. RESULTS: There were 447 patients who met inclusion criteria, of which 123 (28%) were managed in isolation. The median (interquartile range) ED LOS was 259 (210-377) min for the isolation group and 204 (126-297) min for the non-isolation group, a difference in median ED LOS of 55 min (P < 0.001). Isolation was independently associated with a 23% increase in ED LOS (P = 0.002) and doubled the odds of an ED stay of more than 4 h (adjusted odds ratio 2.2 [1.4-3.4], P = 0.001). CONCLUSION: Consistent with the anecdotal experience of Australian ED clinicians, the present study demonstrated an increased ED LOS for patients managed in isolation. Enhanced infection prevention and control precautions will be required during and beyond the current pandemic, creating significant ongoing challenges for emergency care systems.

Impact of COVID-19 State of Emergency restrictions on presentations to two Victorian emergency departments.

OBJECTIVE: To determine if COVID-19 State of Emergency (SOE) restrictions were associated with a reduction in presentations to two urban EDs in Melbourne, Victoria. METHODS: This retrospective observational study included adult patients presenting to The Alfred and Sandringham Hospital EDs during the first month of stage 2 and 3 SOE restrictions (26 March-25 April 2020). Patients transferred from other hospitals or diagnosed with COVID-19 were excluded. The primary outcome was the average number of presentations per day. Secondary outcomes included the average daily number of presentations for pre-specified subgroups defined by triage category and diagnosis. The independent impact of SOE restrictions, adjusted for underlying trends in attendance, was determined using negative binomial regression and reported as an incident rate ratio (IRR) with a 95% confidence interval (CI). RESULTS: Average daily attendance during the exposure period was 174.7. In the absence of SOE restrictions, 278.8 presentations per day were predicted, a reduction of 37.3% (IRR 0.63, 95% CI 0.59-0.67). Attendance was lower than anticipated for all triage categories (especially category 5 [IRR 0.51, 95% CI 0.44-0.59]) and diagnostic groups (including circulatory problems [IRR 0.62, 95% CI 0.50-0.76] and injury [IRR 0.58, 95% CI 0.53-0.63]). There were fewer than predicted presentations for several sentinel diagnoses, including gastroenteritis (IRR 0.27, 95% CI 0.17-0.42) and renal colic (IRR 0.55, 95% CI 0.33-0.92). CONCLUSIONS: SOE restrictions were associated with a significant reduction in ED presentations across a range of triage categories and diagnoses. Public health messaging should emphasise the importance of timely ED attendance for acute illness and injury.

Temperature screening has negligible value for control of COVID-19.

OBJECTIVE: To report the incidence of fever among patients who tested positive for SARS-CoV-2. METHODS: Retrospective cohort study of patients who tested positive for SARS-CoV-2 at a single centre. Temperature at time of testing and on repeat testing within 24 h were collected. RESULTS: At the time of testing, fever was detected (sensitivity) in 16 of 86 (19%; 95% confidence interval 11-28) episodes of positive tests for SARS-CoV-2. With repeat testing, fever was detected in 18 of 75 (24%; 95% confidence interval 15-35) episodes. CONCLUSIONS: In an Australian hospital, screening for fever lacked sensitivity for detection of patients with SARS-CoV-2.

Epidemiology and clinical features of emergency department patients with suspected COVID-19: Results from the first month of the COVID-19 Emergency Department Quality Improvement Project (COVED-2).

OBJECTIVE: The aim of the present study was to describe the epidemiological and clinical features of ED patients with suspected and confirmed COVID-19. METHODS: The COVID-19 Emergency Department (COVED) Project is an ongoing prospective cohort study that includes all adult patients presenting to The Alfred Hospital ED who undergo testing for SARS-CoV-2. Current guidelines recommend testing for patients with fevers or chills, acute respiratory symptoms or a high-risk exposure history, as well as implementation of infection prevention and control precautions for all suspected and confirmed cases. Study outcomes include a positive SARS-CoV-2 test result and intensive respiratory support. RESULTS: In the period 1-30 April 2020, 702 of 3453 ED patients (20%; 95% CI 19-22) were tested, with a significant increase during the study period (incident rate ratio 1.019; 95% confidence interval 1.017-1.021, P < 0.001). The primary outcome of a positive SARS-CoV-2 test was recorded in 14 patients (2%; 95% confidence interval 1-3). Shortness of breath (77%), fatigue (100%), myalgia (67%) and diarrhoea (67%) were common among positive cases, while close contact (9%), fever (0%) and healthcare occupation (0%) were not. No positive cases required intensive respiratory support in the ED. CONCLUSIONS: The volume of ED patients with suspected COVID-19 is increasing. Low numbers of positive cases precluded development of accurate predictive tools, but the COVED Project is fulfilling an important role in monitoring the burden of infection prevention and control requirements on the ED. The increasing number of patients meeting isolation criteria has the potential to impact on patient flow and may lead to ED overcrowding.

Informing emergency care for all patients: The Registry for Emergency Care (REC) Project protocol.

OBJECTIVE: In Australia, the current ED burden related to COVID-19 is from 'suspected' rather than 'confirmed' cases. The initial aim of the Registry for Emergency Care (REC) Project is to determine the impact of isolation processes on the emergency care of all patients. METHODS: The REC Project builds on the COVID-19 Emergency Department Quality Improvement (COVED) Project. Outcomes measured include times to critical assessment and management. RESULTS: Clinical tools will be generated to inform emergency care, both during and beyond the COVID-19 pandemic. CONCLUSIONS: The REC Project will support ED clinicians in the emergency care of all patients.

Epidemiology and clinical features of emergency department patients with suspected COVID-19: Initial results from the COVID-19 Emergency Department Quality Improvement Project (COVED-1).

OBJECTIVE: The COVID-19 Emergency Department (COVED) Quality Improvement Project aims to provide regular and real-time clinical information to ED clinicians caring for patients with suspected and confirmed COVID-19. The present study summarises data from the first 2 weeks of the study. METHODS: COVED is an ongoing prospective cohort study that commenced on 1 April 2020. It includes all adult patients presenting to a participating ED who undergo testing for SARS-CoV-2. Data are collected prospectively and entered into a bespoke registry. Outcomes include a positive SARS-CoV-2 polymerase chain reaction test result and requirement for intensive respiratory support. RESULTS: In the period 1-14 April 2020, 240 (16%) of 1508 patients presenting to The Alfred Emergency and Trauma Centre met inclusion criteria. Of these, 11 (5%) tested positive for SARS-CoV-2. The mean age of patients was 60 years and the commonest symptoms were acute shortness of breath (n = 122 [67%]), cough (n = 108 [56%]) or fever (n = 98 [51%]). Overseas travel or known contact with a confirmed case was reported by 24 (14%) and 16 (10%) patients, respectively. Fever or hypoxia was recorded in 23 (10%) and 11 (5%) patients, respectively. Eleven (5%) patients received mechanical ventilation in the ED, of whom none tested positive for SARS-CoV-2. CONCLUSIONS: Among patients presenting to a tertiary ED with suspected COVID-19, only a small proportion tested positive for SARS-CoV-2. Although the low incidence of positive cases currently precludes the development of predictive tools, the COVED Project demonstrates that the rapid establishment of an agile clinical registry for emergency care is feasible.

Informing emergency care for COVID-19 patients: The COVID-19 Emergency Department Quality Improvement Project protocol.

OBJECTIVES: There is an urgency to support Australian ED clinicians with real-time tools as the COVID-19 pandemic evolves. The COVID-19 Emergency Department (COVED) Quality Improvement Project has commenced and will provide flexible and responsive clinical tools to determine the predictors of key ED-relevant clinical outcomes. METHODS: The COVED Project includes all adult patients presenting to a participating ED and meeting contemporary testing criteria for COVID-19. The dataset has been embedded in the electronic medical record and the COVED Registry has been developed. RESULTS: Outcomes measured include being COVID-19 positive and requiring intensive respiratory support. Regression methodology will be used to generate clinical prediction tools. CONCLUSION: This project will support EDs during this pandemic.