Disclaimer: The views presented here are of the authors and do not necessarily reflect the views of United Hospital Fund, its staff, or its board of directors.
During the early days of the COVID-19 pandemic, the National Syndromic Surveillance Program (NSSP) reported that emergency department (ED) visits in the United States had decreased by 42 percent. In my own emergency room at Lenox Hill Hospital, there was a decrease of nearly 25 percent in complaints of chest pain, as well as a 39 percent decrease in patients diagnosed with an acute stroke. Unfortunately, these numbers do not mean that a significant share of patients were suddenly healthier and without need of emergency medical care.
Between March 11 and May 2, 2020, the New York City Department of Health and Mental Hygiene (DOHMH) reported that 5,293 “excess deaths” occurred that could not be confirmed or identified with COVID-19. Excess deaths are the number of deaths above expected seasonal baseline levels, regardless of the reported cause.
It is clear that the public health messaging advocating for the avoidance of unnecessary health care use to minimize contact with COVID-19 and to allow for capacity to manage the surge had unintended consequences: Some patients were clearly forgoing medical care for life-threatening conditions. The result is a public health crisis that will require a multi-pronged approach to remedy. It also raises valid questions about avoiding unnecessary emergency department use for patients with minor acute medical conditions, some of whom were able to receive care through telemedicine and other means.
Responding to the Immediate Crisis
Health care providers and others must emphasize that the risk of death for patients seeking emergency care exceeds the risk of contracting COVID-19. The public must be made aware that emergency departments are following CDC-recommended infection-control measures. This includes social-distancing of all patients and separating suspected and confirmed COVID-19 patients from others. Anyone entering the emergency room, including patients, health care staff, and visitors, is required to wear a mask and undergo screening and temperature checks. The number of visitors is strictly limited.
Just as important as the message itself—how should it be delivered? Communication campaigns focused on appropriate patients returning to emergency departments need to be based on the latest expert recommendations, leverage multiple media platforms, and be inclusive in terms of demographics and socio-economic status. It is also clear that messaging is most effective when delivered by a trusted source. Catherine L. King et al. found that patients had high levels of trust in doctors. Specifically for COVID-19, Zan Lep et al. found that medical professionals and scientists had the highest level of credibility in terms of delivering effective health communication. Stephen Love, CEO of Dallas-Fort Worth Hospital Council, indicated in Modern Healthcare that his emergency department volumes normalized when health care providers were involved in raising awareness.
Lessons Learned about Avoidable ED Use
In addition to a drop-off in ED visits by patients who required emergency care throughout the COVID-19 pandemic, we also witnessed a decline in visits by patients with low-acuity conditions, such as superficial injuries, sprains, and strains. It became clear that many of these patients were able to successfully receive care via telemedicine and other alternatives. One major unintended consequence of the pandemic may be that we have learned how to successfully reverse the trend of increased, avoidable emergency department use.
In October 2007, the Institute for Healthcare Improvement (IHI) proposed a framework for reducing avoidable ED visits. One key concept is that patients be categorized into “streams,” which would include a cohort of patients with a common health issue that can be managed outside of the ED—if there is a clear understanding of their needs for support in the community. During the pandemic, for example, EDs nationwide were able to successfully put protocols in place that allowed for remote monitoring of COVID-19 patients who did not require hospitalization. Sonia Shah et al. published on the successful management of 77 suspected and confirmed COVID-19 patients via telephonic consultation and home oxygen level monitoring.
FAIR Health, a nonprofit that monitors trends in telehealth, reported that the growth of telemedicine in the U.S. since the COVID-19 pandemic surge has been tremendous. In the Northeastern region of the U.S., which was hit the hardest in March, telehealth claims grew by 15,503 percent—from 0.07 percent of medical claims in March 2019 to 11.07 percent in March 2020. While there are many factors that will determine if this momentum continues, it is probably safe to conclude that market penetration will increase after COVID-19. Ashwin Ramaswamy et al. reported significant patient satisfaction increases with video conferencing during the COVID-19 pandemic compared to in-person visits during a similar time period in the previous year.
The toll from COVID-19 is horrendous and heartbreaking. But the pandemic has also given us a glimpse into a more efficient, safe, and satisfying patient experience. Issues that still need to be resolved for remote care include the permanency of reimbursement, parity of payment between in-person and telehealth, and universal access to broadband. Finally, telehealth can give patients a safer and viable option beyond the binary choice of seeking care in an emergency room or not.
As we respond to a public health crisis brought about by COVID-19, we may also have a pivotal opportunity to make emergency care better for everyone—we should seize the moment.
Yves Duroseau, MD, MPH, is chairman of emergency medicine at Lenox Hill Hospital.
United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from Yves Duroseau, MD, MPH, examines several critical issues related to emergency department use during the COVID-19 pandemic. – UHF President Tony Shih