The National Syndromic Surveillance Program (NSSP) found that emergency department (ED) visits declined 42% during the early COVID-19 pandemic, from a mean of 2.1 million per week (March 31–April 27, 2019) to 1.2 million (March 29–April 25, 2020), with the steepest decreases in persons aged less than 14 years, females, and the Northeast.
The proportion of infectious disease–related visits was four times higher during the early pandemic period. To minimize SARS-CoV-2 transmission risk and address public concerns about visiting the ED during the pandemic, the Centers for Disease Control and Prevention (CDC) recommends continued use of virtual visits and triage help lines and adherence to the CDC infection control guidance.
On March 13, 2020, the United States declared a national emergency to combat COVID-19. As the number of persons hospitalized with COVID-19 increased, early reports suggested sharp drops in the numbers of persons seeking emergency medical care for other reasons.
To quantify the effect of COVID-19 on U.S. emergency department (ED) visits, the CDC compared the volume of ED visits during four weeks early in the pandemic March 29–April 25, 2020 (weeks 14 to 17; the early pandemic period) to that during March 31–April 27, 2019 (the comparison period). During the early pandemic period, the total number of U.S. ED visits was 42% lower than during the same period a year earlier, with the largest declines in visits in persons aged less than 14 years, females, and the Northeast region.
Health messages that reinforce the importance of immediately seeking care for symptoms of serious conditions, such as myocardial infarction, are needed. To minimize SARS-CoV-2, the virus that causes COVID-19, transmission risk and address public concerns about visiting the ED during the pandemic, the CDC recommends continued use of virtual visits and triage help lines and adherence to the CDC infection control guidance.
During an early four-week interval in the COVID-19 pandemic, ED visits were substantially lower than during the same four-week period during the previous year; these decreases were especially pronounced for children and females and in the Northeast.
In addition to diagnoses associated with lower respiratory disease, pneumonia, and difficulty breathing, the number and ratio of visits (early pandemic period versus comparison period) for cardiac arrest and ventricular fibrillation increased.
The number of visits for conditions including nonspecific chest pain and acute myocardial infarction decreased, suggesting that some persons could be delaying care for conditions that might result in additional mortality if left untreated. Some declines were in categories including otitis media, superficial injuries, and sprains and strains that can often be managed through primary or urgent care.
Future analyses will help clarify the proportion of the decline in ED visits that were not preventable or avoidable such as those for life-threatening conditions, those that were manageable through primary care, and those that represented actual reductions in injuries or illness attributable to changing activity patterns during the pandemic (such as lower risks for occupational and motor vehicle injuries or other infectious diseases).
The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public. Persons who use the ED as a safety net because they lack access to primary care and telemedicine might be disproportionately affected if they avoid seeking care because of concerns about the infection risk in the ED.
Syndromic surveillance has important strengths, including automated electronic reporting and the ability to track outbreaks in real time. Among all visits, 74% are reported within 24 hours, with 75% of discharge diagnoses typically added to the record within 1 week.
To assess trends in ED visits during the pandemic, the CDC analyzed data from the National Syndromic Surveillance Program (NSSP), a collaborative network developed and maintained by the CDC, state and local health departments, and academic and private sector health partners to collect electronic health data in real time. The national data in NSSP includes ED visits from a subset of hospitals in 47 states (all but Hawaii, South Dakota, and Wyoming), capturing approximately 73% of ED visits in the United States able to be analyzed at the national level. During the most recent week, 3,552 EDs reported data. Total ED visit volume, as well as patient age, sex, region, and reason for visit were analyzed.
The lowest number of visits reported to NSSP occurred during April 12–18, 2020 (week 16). Although visits have increased since the nadir, the most recent complete week (May 24–30, week 22) remained 26% below the corresponding week in 2019. The number of ED visits decreased 42%, from a mean of 2,099,734 per week during March 31–April 27, 2019, to a mean of 1,220,211 per week during the early pandemic period of March 29–April 25, 2020. Visits declined for every age group, with the largest proportional declines in visits by children aged ≤10 years (72%) and 11–14 years (71%). Declines in ED visits varied by U.S. Department of Health and Human Services region, with the largest declines in the Northeast (Region 1, 49%) and in the region that includes New Jersey and New York (Region 2, 48%). Visits declined 37% among males and 45% among females across all NSSP EDs between the comparison and early pandemic periods.
Among all ages, an increase of >100 mean visits per week from the comparison period to the early pandemic period occurred in eight of the top 200 diagnostic categories. These included:
· exposure, encounters, screening, or contact with infectious disease (mean increase 18,834 visits per week);
· COVID-19 (17,774);
· other general signs and symptoms (4,532);
· pneumonia not caused by tuberculosis (3,911);
· other specified and unspecified lower respiratory disease (1,506);
· respiratory failure, insufficiency, or arrest (776);
· cardiac arrest and ventricular fibrillation (472); and
· socioeconomic or psychosocial factors (354).
The largest declines were in visits for abdominal pain and other digestive or abdomen signs and symptoms (–66,456), musculoskeletal pain excluding low back pain (–52,150), essential hypertension (–45,184), nausea and vomiting (–38,536), other specified upper respiratory infections (–36,189), sprains and strains (–33,709), and superficial injuries (–30,918). Visits for nonspecific chest pain were also among the top 20 diagnostic categories for which visits decreased (–24,258). Although not in the top 20 declining diagnoses, visits for acute myocardial infarction also declined (–1,156).
Healthcare systems should continue to address public concern about exposure to SARS-CoV-2 in the ED through adherence to the CDC infection control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of COVID-19.
Wider access is needed to health messages that reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction. Expanded access to triage telephone lines that help persons rapidly decide whether they need to go to an ED for symptoms of possible COVID-19 infection and other urgent conditions is also needed. For conditions that do not require immediate care or in-person treatment, health care systems should continue to expand the use of virtual visits during the pandemic.
