Epidemiology of patients who died in the emergency departments and need of end-of-life care in Korea from 2016 to 2019.

The need of palliative care at the end-of-life in the emergency departments (ED) is growing. The study aims to investigate the epidemiology of patients who died during care in ED using nationwide database, and to estimate the need for palliative care in the ED. A retrospective observational study was conducted using the National Emergency Department Information System (NEDIS) database. Patients who died during ED care between 2016 and 2019 were included. Palliative care-eligible disease was defined as cancer (C00-C99 of ICD-10), chronic respiratory disease (CRD, J44-J46), chronic liver disease (CLD, K70-K77), and heart failure (HF, I50). Among the 36,538,486 ED visits during 4 years, 34,086 ED deaths were included. The crude incidence rate of ED deaths per 100,000 person-year was steady between 16.6 in 2016 and 16.3 in 2019 (p-for-trend = 0.067). Only 3370 (9.9%) ED deaths were injury, while 30,716 (90.1%) deaths were related to diseases. The most common ED diagnosis was cardiac arrest (22.1%), followed by pneumonia (8.6%) and myocardial infarction (4.7%). In cases of disease-related ED deaths, about 34.0% stayed longer than 8 h in the ED (median (interquartile range): 4.5 (1.9-11.7) h) and 44.2% received cardiopulmonary resuscitation (CPR) at end-of-life time. A quarter of the disease-related ED deaths were diagnosed with palliative care eligible disease: cancer (16.9%), CLD (3.8%), HF (3.5%), and CRD (1.4%). Cancer patients received less CPR (23.4%) and stayed longer in the ED (median (interquartile range): 7.3 (3.2-15.9) h). Over the past 4 years, more than 30,000 patients, including 5200 cancer patients, died during care in the ED. A quarter of disease-related ED death were patients with palliative care-eligible condition and more than 30% of them stayed longer than 8 h in the ED before death. It is time to discuss about need of palliative care in the ED.

Effect of social distancing on injury incidence during the COVID-19 pandemic: an interrupted time-series analysis.

OBJECTIVES: To evaluate the effects of social distancing on the incidence and characteristics of injuries during the COVID-19 pandemic. DESIGN AND SETTING: This cross-sectional study used the National Emergency Department Information System (NEDIS) database. PARTICIPANTS: Injured patients who visited all 402 emergency departments (EDs) between 29 February and 29 May 2020 (after-distancing), and in the corresponding period in 2019 (before distancing) to control for seasonal influences. OUTCOME MEASURES: The study outcome was the incidence of injury. Using the interrupted time-series analysis models, we analysed weekly trends of study outcomes in both periods (before and after distancing), the step change (the effect of intervention), and the slope change over two periods (the change in the effect over time). RESULTS: The incidence rates of injury per 100 000 person-days were 11.2 and 8.6 in the before-distancing and after-distancing periods, respectively. In the after-distancing period, the incidence rate of injury decreased (step change -3.23 (95% CI -4.34 to -2.12) per 100 000 person-days) compared with the before-distancing period, while the slope change was 0.10 (95% CI 0.04 to 0.24). The incidence rate ratios of all injuries and intentional injuries for the after-distancing period were 0.67 (95% CI 0.60 to 0.75) and 1.28 (95% CI 1.18 to 1.40), respectively, compared with the before-distancing period. CONCLUSIONS: Fewer injuries occurred after the implementation of social distancing programme compared with the same period in the previous year. However, this effect gradually decreased postimplementation.

Impact of the COVID-19 Pandemic on Emergency Care Utilization and Outcomes in Pediatric Patients with Intussusception.

BACKGROUND: We determined whether a decrease in healthcare utilization patterns during the COVID-19 pandemic affected the treatment process of pediatric patients with intussusception. METHODS: Patients with suspected intussusception who had ICD-10 code K561 as their discharge diagnosis from the national database were selected, and those who underwent either radiologic and/or surgical reduction were defined as true intussusception patients. We compared the time periods from patients visiting the ED to ultrasound, radiologic reduction and/or surgical reduction between the study group (first half of 2020, COVID-19 period) and the control groups (control group 1: first half of 2019, control group 2: second half of 2019). RESULTS: The number of suspected intussusception patients in each group was 1223, 1576, and 624, and the incidence rates were 7.85, 11.30, and 4.19 per 100,000 person-half-years (control group 1, control group 2, study group, respectively, p < 0.05). No differences in terms of the time from the ED visit to ultrasound, radiological reduction and/or surgical reduction were noted between the study group and the control groups. CONCLUSIONS: In Korea, the COVID-19 pandemic did not significantly affect the ED treatment process or the results of patients with intussusception.

The impact of COVID-19 on the patterns of emergency department visits among pediatric patients.

OBJECTIVES: This study aimed to investigate the patterns of pediatric patients visiting emergency departments (EDs) before and after the COVID-19 pandemic and evaluate the interactive effect between the COVID-19 outbreak and age groups. METHODS: We performed a cross-sectional study using the nationwide emergency patient database in Korea from January 2019 to December 2020. Pediatric patients (≤18 years) who visited all 402 nationwide EDs were included. The age- and sex-standardized incidence rates of pediatric ED visits per 1,000,000 person-days were calculated, and the incidence rate ratio (IRR) was calculated. The adjusted odds ratio (aOR) and 95% confidence interval (CI) of in-hospital mortality were calculated by a multivariable logistic regression. RESULTS: Among 2,808,756 patients, 1,835,045 (65.3%) patients visited before COVID-19, and 973,711 (34.7%) patients visited after the COVID-19 period. The standardized incidence rates of ED visits per 1,000,000 person-days were 589.3 in the before COVID-19 group and 326.9 in the after COVID-19 group (IRR (95% CI): 0.55 (0.53-0.58)). By diagnosis, the IRRs (95% CI) of mental health disorders (0.84 (0.42-1.65)) and self-harm or suicidal attempts (0.99 (0.38-2.59) were not significant, while the incidence rate of infectious disease was significantly decreased (0.48 (0.42-0.54)). The aOR (95% CI) of in-hospital mortality after COVID-19 was 1.58 (1.44-1.73) compared to that before COVID-19. CONCLUSIONS: During the COVID-19 pandemic, the incidence of pediatric ED visits decreased, and these effects differed by age group. Age-specific policies are needed to ensure that children receive the care they need at the right time.

Impact of the COVID-19 Pandemic on the Incidence and Characteristics of Patients with Psychiatric Illnesses Visiting Emergency Departments in Korea.

The global coronavirus disease 2019 (COVID-19) pandemic has had wide-ranging effects on the mental health of the public. This study aimed to investigate the impact of the COVID-19 pandemic on the characteristics of psychiatric patients who visited emergency departments (ED) during this time. A cross-sectional study was conducted including patients visiting 402 nationwide EDs from 27 January 2020 to 29 June 2020 (22 weeks; during-COVID) and the corresponding period in 2019 (28 January 2019 to 30 June 2019, 22 weeks; before-COVID) to control for seasonal influences. Among the 6,210,613 patients who visited the ED, 88,520 (2.5%) patients who visited before the pandemic and 73,281 (2.7%) patients who visited during the pandemic had some kind of psychiatric illness. The incidence rates of psychiatric self-harm increased from 0.54 before the pandemic to 0.56 during the pandemic per 1,000,000 person-days (p = 0.04). Age- and sex-standardized rates of psychiatric illnesses per 100,000 ED visits increased during the pandemic (rate differences (95% CIs); 45.7 (20.1-71.4) for all psychiatric disorders and 42.2 (36.2-48.3) for psychiatric self-harm). The incidence of psychiatric self-harm and the proportion of psychiatric patients visiting EDs increased during the COVID-19 pandemic.

Analysis of the Impact of the Coronavirus Disease Epidemic on the Emergency Medical System in South Korea Using the Korean Triage and Acuity Scale.

PURPOSE: Severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19), has spread worldwide. Global health systems, including emergency medical systems, are suffering from a lack of medical resources. Using a method for classifying patients visiting the emergency department (ED), we aimed to investigate trends in emergency medical system usage during the COVID-19 epidemic in Korea. MATERIALS AND METHODS: This retrospective observational study included patients who visited emergency medical institutions registered with the National Emergency Department Information System database from January 1, 2017 to May 31, 2020. The primary outcome was identification of changes in the distribution of patients visiting the ED according to the type of emergency medical institution. The secondary outcome was a detailed comparison of Korean Triage and Acuity Scale (KTAS) levels and patient distributions before and during the infectious disaster crisis period. RESULTS: Severe patients visited regional emergency centers (RECs) and local emergency centers (LECs) more frequently during the COVID-19 period, and disposition status warranting admission to the intensive care unit or resulting in death was more common in RECs and LECs during the COVID-19 period [RECs, before COVID-19: 300686 (6.3%), during COVID-19: 33548 (8.0%) (p<0.001); LECs, before COVID-19: 373593 (3.7%), during COVID-19: 38873 (4.5%) (p<0.001)]. CONCLUSION: During the COVID-19 period, severe patients were shifted to advanced emergency medical institutions, and the KTAS better reflected severe patients. Patient distribution according to the stage of emergency medical institution improved, and validation of the KTAS triage increased more in RECs.

Effects of Emergency Care-related Health Policies during the COVID-19 Pandemic in Korea: a Quasi-Experimental Study.

BACKGROUND: The purpose of this study was to review the nationwide emergency care-related health policies during the coronavirus disease 2019 (COVID-19) pandemic disaster in Korea and to analyze the effects of the policies on the safety of patients who visit emergency departments (EDs) during this period. METHODS: This study is a quasi-experiment study. The study population was patients who visited all 402 EDs in Korea between December 31, 2019 and May 13, 2020, using the National Emergency Department Information System (NEDIS) database. The study period was classified into 5 phases according to the level of national crisis warning of infectious disease and the implementation of emergency care-related health policies, and all study phases were 27 days. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay (LOS) in the ED during the COVID-19 outbreak. RESULTS: The number of ED visits during the study period was 2,636,341, and the in-hospital mortality rate was 1.4%. The number of ED visits decreased from 803,160 in phase 1 to 496,619 in phase 5 during the study period. For in-hospital mortality, the adjusted odds ratio (OR) (95% confidence interval) was 0.77 (0.74-0.79) in phase 5 compared to phase 3. Additionally, by subgroup, the ORs were 0.69 (0.57-0.83) for the patients with acute myocardial infarction and 0.76 (0.67-0.87) for severe trauma in phase 5 compared to phase 3. The ED LOS increased while the number of ED visits decreased as the COVID-19 pandemic progressed, and the ED LOS declined after policy implementation (beta coefficient: -5.3 [-6.5 to -4.2] minutes in phase 5 compared to phase 3). CONCLUSION: Implementing appropriate emergency care policies in the COVID-19 pandemic would have contributed to improving the safety of all emergency patients and reducing in-hospital mortality by preventing excessive deaths.

Interaction Effects between COVID-19 Outbreak and Community Income Levels on Excess Mortality among Patients Visiting Emergency Departments.

BACKGROUND: The objective of this study was to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on excess in-hospital mortality among patients who visited emergency departments (EDs) and to assess whether the excess mortality during the COVID-19 pandemic varies by community income level. METHODS: This is a cross-sectional study using the National Emergency Department Information System (NEDIS) database in Korea. The study population was defined as patients who visited all 402 EDs with medical conditions other than injuries between January 27 and May 31, 2020 (after-COVID) and for the corresponding time period in 2019 (before-COVID). The primary outcome was in-hospital mortality. The main exposure was the COVID-19 outbreak, and the interaction variable was county per capita income tax. We calculated the risk-adjusted in-hospital mortality rates by COVID-19 outbreak, as well as the difference-in-difference of risk-adjusted rates between the before-COVID and after-COVID groups according to the county income tax using a multilevel linear regression model with the interaction term. RESULTS: A total of 11,662,167 patients (6,765,717 in before-COVID and 4,896,450 in after-COVID) were included in the study with a 1.6% crude in-hospital mortality rate. The risk-adjusted mortality rate in the after-COVID group was higher than that in the before-COVID group (1.82% vs. 1.50%, difference: 0.31% [0.30 to 0.33]; adjusted odds ratio: 1.22 [1.18 to 1.25]). The excess in-hospital mortality rate of the after-COVID in the lowest quartile group of county income tax was significantly higher than that in the highest quartile group (difference-in-difference: 0.18% (0.14 to 0.23); P-for-interaction: < 0.01). CONCLUSION: During the COVID-19 pandemic, there was excess in-hospital mortality among patients who visited EDs, and there were disparities in excess mortality depending on community socioeconomic positions.

Impact of temporary closures of emergency departments during the COVID-19 outbreak on clinical outcomes for emergency patients in a metropolitan area.

BACKGROUND: During the early phase of the coronavirus disease 2019 (COVID-19) outbreak, many emergency departments (EDs) were exposed to COVID-19 and were temporarily closed according to national protocol of Korea. We aimed to evaluate the effect of concurrent and recurrent temporary closures of EDs on the clinical outcomes of patients who visited EDs during the COVID-19 outbreak. METHODS: This cross-sectional study used a nationwide emergency patient database. Patients who visited one of the 46 EDs in Daegu and Gyeongbuk between January 21 and April 14, 2020 were included. The main exposure variable was the first medical contact (ED visit or 119 call to emergency medical services (EMS)) during closure of at least one ED. There were 25 temporary closures of six Level-1 and Level-2 EDs between February 18 and March 17, 2020. We constructed a dataset by performing bidirectional crossover matching and conducted a conditional logistic regression analysis where the primary outcome was in-hospital mortality. RESULTS: Of the 94,360 eligible study participants, 36,327 were classified into the non-EMS-use group and 10,116 were classified into the EMS-use group. In-hospital mortality rates were 2.0% and 1.6% for the temporary-closure and no-closure groups in the non-EMS-use group (p-value, 0.03) and 8.7% and 7.4% in the EMS-use group (p-value, 0.02), respectively. In the conditional logistic analysis for in-hospital mortality, the odds ratios (95% confidence intervals) of the temporary-closure group compared the no-closure group were 1.22 (1.03-1.44) among the non-EMS-use group and 1.23 (1.04-1.46) among the EMS-use group. CONCLUSION: The temporary closures of EDs due to the unpredicted COVID-19 exposure resulted in an increase in emergency patients' in-hospital mortality rates irrespective of whether they used EMS. Preparing regional EMS systems to cope with new outbreaks is essential to protect the safety of all citizens.