How avoiding emergency department visits can have serious consequences

Amidst the COVID-19-hit world, Dr Tamorish Kole, President, Asian Society for Emergency Medicine (ASEM) shares his insights on how to move towards the new normal and redesign the process, so that emergency care is delivered and demanded at right place at right time

The emergency department is the first point of contact for many patients of COVID-19. Emergency department (ED) volume is down nearly 50 per cent in many countries struggling with the COVID-19 epidemic. There is increasing evidence that patients with medical emergencies are avoiding the emergency care at hospitals because of fear of contracting COVID-19, leading to increased morbidity and mortality. At the same time, a regional Emergency Medical Services (EMS) in the US reported highest-ever number of cardiac arrests out of hospital in March 2020, which is 45 per cent more than the previous month, suggesting that patients were waiting too long to seek emergency cardiac care. A recent article in the Journal of the American College of Cardiology indicated nearly 40 per cent reduction in use of cardiac catheterisation labs to treat acute heart attacks. A striking feature of the pandemic internationally has been the fall in ED presentations relating to trauma, accidents, drugs and alcohol. The number of patients with intermittent conditions like back pain and migraine – who often attend the ED for symptomatic relief – has also fallen over the past six months. Prior experience from Ebola outbreak (2014 – 2015) suggests that the increased number of deaths caused by measles, malaria, HIV/AIDS and tuberculosis attributable to health system failures.

In India, road crash is one of the major reasons for visits to ED. Recent media reports suggest that road crash is 10 times more fatal than COVID-19, even during lockdown period. In order to provide the best care within golden hour, the emergency departments must be active 24×7.

The COVID-19 epidemic led to a massive amount of severely ill patients presenting to the ED (hospitals) in a short period of time. With initial challenges of hospital staff being turned COVID-positive, temporary closure of healthcare facilities, imposed lockdown (for good) and fear of contracting COVID have resulted in similar situation in many hospitals. Although, number of patients still increasing India’s recovery rate is commendable, thanks to continuous efforts of all stakeholders.

So, if the patients are not seeking emergency care, as they should, a rootcause analysis should be done, and corrective actions need to be taken by all concerned.

Some of the global common themes on why there is a drop in seeking emergency care are as follows:

• Hospitals are perceived as reservoirs of infection and patients want to avoid hospital visits because there is a greater risk of exposure to the virus. They are also worried that they may not be able to appropriately maintain a safe social distance in a busy crowded emergency department, as it was before.
• Patients are not well-informed about the current strategy of the hospitals, and particularly emergency departments, on how they have restructured the operation to reduce the risk of cross exposure. Many are also curious about what happens when once a patient is screened positive and there is a need to safeguard other patients.
• Some patients feel disconnected from their doctors and hospitals due to current fear of visiting hospitals physically. Some patients stated that if they were having a health emergency, they would have gone straight to the ED, but are now afraid of doing so.

The big question is how we move towards the new normal and redesign our process, so that emergency care is delivered and demanded at right place at right time. Some of the international practices, which have worked are:

• Create a physical divide to create an emotional divide: Imagine a pre-COVID emergency department – crowded waiting areas, clinical care happening side by side and staff stretched out to their maximum capacity at times, moving from one area to other to deliver care. All these are impossible to imagine now. The concept of split ED (split and stretch operations to maintain social distancing and cross exposure) has proven amazingly effective. As per the Government of India guidelines also, patients at high risk for COVID-19 needed to be appropriately screened, triaged and separated.
• Zoning: Patients meeting case definition criteria should be streamed into a dedicated ‘high-risk’ treatment zone within the ED with immediate isolation from other waiting patients. The Australasian College of Emergency Medicine (ACEM) recommends that any high-risk zone is (a) clearly demarcated, with a minimum number of entry and exit points and designated areas for staff to don and doff PPE; (b) described using neutral language, such as a ‘hot’ or ‘red’ zone; (c) staffed by a team of dedicated clinicians separate from those looking after low-risk patients.
• Mobile or modular care units: Many hospitals and states have opened COVID-19 testing centres out of hospital building. The benefits of such units are to keep possible sick patients in their cars, and better protect healthcare staff and other patients inside hospitals. This can be built near EDs for the same reasons.
• Staffing: Staff working in high-risk zone should (a) wear appropriate PPE at all times; (b) is not permitted to bring food into this or any other clinical area; (c) takes regular, planned breaks to preserve health and wellbeing, especially in the setting of continuous PPE use.
• Communicate clear and transparent information about services and risk: Communications needed to come from the hospital leadership as a trusted source of information and convey that the hospital is open for all operations, including emergency care. It will be good if we communicate the precautions in place to keep patients and staff safe and provide guidance about when to come and what to expect in the ED.
• Doctor-led approach: The doctor-led approach of healthcare across the world has been swept away by the imposed lockdown, restrictions, containments and fear of hospital visits. Patients, who previously considered the only way of receiving healthcare was by meeting their doctors face-to-face, explaining their symptoms, being examined and ultimately getting diagnosed and treated, have, in a few short weeks, found other mechanisms to receive care. Patients have found themselves interacting via apps, online tools and video conferences, in many cases, with a more responsive approach. Webinars and virtual group discussions to target groups is useful for emergency care as well. There are certain groups of vulnerable patients who may need emergency care compared to others. This includes patients with known heart disease, high blood pressure, diabetes, chronic kidney and respiratory disease, cancer patients, etc. Regular follow ups and advice on when to attend emergency can be greatly beneficial at times.

In Hong Kong, researchers found delays in a small number of patients with acute heart attack (STEMI) seeking medical help after institution of infection control measures at receiving hospitals. Infection control is not a new practice within the healthcare community, yet gaining public confidence through better practices can result in reducing undue delays and fear of seeking timely emergency care.

In addition, emergency care must also include telehealth as one of the delivery options. Telehealth has several key strengths that can enhance an emergency response when environmental or biological hazards are present. During infectious disease outbreaks, telehealth can enable remote triaging of patients and provide rapidly accessible information through technology on where to seek care – such as use of chatbots in Singapore during COVID-19. Additionally, telehealth can enable people to navigate the health system, find real bed availability for non-COVID emergencies (like Delhi Govt App for COVID beds) and access routine care during an infectious disease outbreak. This strategy is beneficial in both ways– to seek emergency care when needed and avoid hospital visits when indicated.

COVID-19 has taught the world that no health system can be maintained to have the idle capacity to step up to delivering care in a situation such as this pandemic. Instead, it relies on the whole population to do its duty to support the health systems, to help themselves where possible and to utilise healthcare appropriately. As we steer through this pandemic and reshape our healthcare system, we must quickly focus on delivering emergency care to all patients and build trust in them that they should not neglect their prevailing health issues and emergencies.