Persons experiencing chest pain, loss of motor function, altered mental status or other life-threatening issues should seek immediate emergency care, regardless of the pandemic, addresses the Centers for Disease Control and Prevention (CDC).
Communication from public health and healthcare professionals should reinforce the importance of timely care for acute health conditions and assure the public that emergency departments (Eds) are implementing infection prevention and control guidelines to ensure the safety of patients and healthcare personnel.
By May 2020, national syndromic surveillance data found that ED visits had declined 42% during the early months of the pandemic. This report describes trends in ED visits for three acute life-threatening health conditions (myocardial infarction [MI, also known as heart attack], stroke and hyperglycemic crisis), immediately before and after declaration of the COVID-19 pandemic as a national emergency.
These conditions represent acute events that always necessitate immediate emergency care, even during a public health emergency such as the COVID-19 pandemic. In the 10 weeks following the emergency declaration (March 15–May 23, 2020), ED visits declined 23% for MI, 20% for stroke and 10% for hyperglycemic crisis, compared with the preceding 10-week period (January 5–March 14, 2020).
EDs play a critical role in diagnosing and treating life-threatening conditions that might result in serious disability or death. Persons experiencing signs or symptoms of serious illness, such as severe chest pain, sudden or partial loss of motor function, altered mental state, signs of extreme hyperglycemia or other life-threatening issues, should seek immediate emergency care, regardless of the pandemic. Clear, frequent, highly-visible communication from public health and health care professionals is needed to reinforce the importance of timely care for medical emergencies and to assure the public that EDs are implementing infection prevention and control guidelines that help ensure the safety of their patients and health care personnel.
In the weeks following the declaration of COVID-19 as a national emergency on March 13, 2020, NSSP identified substantial reductions in numbers of ED visits by males and females in all age groups for three potentially life-threatening conditions: MI (23% decrease), stroke (20%) and hyperglycemic crisis (10%). These estimates are consistent with, but smaller in relative magnitude than, the 42% overall decline in ED visits observed during the early pandemic period. The largest absolute differences were observed in adults aged ≥65 years for MI and stroke, and adults aged 18–44 years and persons aged <18 years for hyperglycemic crisis.
The substantial reduction in ED visits for these life-threatening conditions might be explained by many pandemic-related factors including fear of exposure to COVID-19, unintended consequences of public health recommendations to minimize nonurgent healthcare, stay-at-home orders or other reasons. A short-term decline of this magnitude in the incidence of these conditions is biologically implausible for MI and stroke, especially for older adults, and unlikely for hyperglycemic crisis, and the finding suggests that patients with these conditions either could not access care or were delaying or avoiding seeking care during the early pandemic period. There have been reports of excess mortality during the COVID-19 pandemic wherein deaths not associated with confirmed or probable COVID-19 might have been directly or indirectly attributed to the pandemic. The striking decline in ED visits for acute life-threatening conditions might partially explain observed excess mortality not associated with COVID-19.
Previous studies have also reported significant reductions in hospital admissions for MI and stroke during the COVID-19 pandemic. For example, a study of nine high-volume U.S. cardiac catheterization laboratories found a 38% decrease in activations for heart attacks during March 2020 compared with the 14 months before the pandemic. Further, large hospital systems in California, Massachusetts and New York City have reported 43%–50% reductions in admissions for MI and other acute cardiovascular conditions during the pandemic, and neuroimaging data from approximately 850 U.S. hospitals indicate a 39% reduction in the number of patients who were evaluated for signs of stroke. Decreases in ED visits for hyperglycemic crisis might be less striking because patient recognition of this crisis is typically augmented by home glucose monitoring and not reliant upon symptoms alone, as is the case for MI and stroke. The decrease in visits for hyperglycemic crisis merits further study because there are few published reports on this topic.
MI, stroke, and hyperglycemic crisis are common life-threatening conditions that require urgent attention to reduce associated morbidity and mortality. Heart disease is the leading cause of death and stroke is the fifth leading cause of death in the United States: someone in the United States has a heart attack every 40 seconds, and approximately 795,000 persons have a stroke annually.
Diabetes affects 34 million Americans, and uncontrolled hyperglycemia (high blood glucose), can lead to diabetic ketoacidosis or a hyperosmolar hyperglycemic state, life-threatening but preventable metabolic complications of diabetes. It is important for all persons to know the warning signs of MI, stroke, and hyperglycemic crisis and understand that immediate medical attention for these acute issues can prevent serious heart or brain damage, metabolic complications of diabetes or death. The sooner emergency care begins, the better are the chances for survival. Even in the face of the COVID-19 pandemic, emergency care can and should be accessed and provided without delay.
The CDC used data from its National Syndromic Surveillance Program (NSSP) to assess trends in ED visits from week 1, 2019 through week 21, 2020 for three life-threatening health conditions: MI, stroke and hyperglycemic crisis. NSSP is a collaboration among CDC, federal partners, local and state health departments, and academic and private sector partners to collect, analyze, and share electronic patient encounter data received from emergency departments, urgent and ambulatory care centers, inpatient health care settings, and laboratories for public health action.
The findings in this report are subject to at least five limitations. First, NSSP coverage is not uniform across or within states, and hospitals reporting to NSSP change over time; however, NSSP captures approximately 73% of the ED data analyzable at the national level. Second, conditions were defined using ICD-10 diagnosis codes. Differences in coding practices might exist; however, coding for common conditions, especially the life-threatening conditions described in this report, is likely consistent. Third, NSSP does not capture mortality data, and it is not known whether patients with MI or stroke sought treatment elsewhere or died at home. Fourth, despite allowing two weeks from the end of week 21 before analyzing the data, the findings from the final weeks might be slightly underestimated because of delayed reporting.
Finally, seasonal effects in trends in ED visits might exist; however, a proximal comparison period was best for this analysis to minimize other factors that might have affected trends in disease incidence or health care–seeking behavior between years. Despite these limitations, this study also has important strengths. NSSP is a national surveillance system with automated electronic reporting and the ability to detect and monitor health events in near real time, and this analysis was restricted to hospitals with consistent reporting on patients’ diagnoses at discharge to minimize effects of differential reporting.
At least one in five expected U.S. ED visits for MI or stroke and one in 10 ED visits for hyperglycemic crisis did not occur during the initial months of the COVID-19 pandemic. Patients might have delayed or avoided seeking care because of fear of COVID-19, unintended consequences of recommendations to stay at home, or other reasons. EDs play a critical role in treating acute conditions that might result in permanent disability or death. Persons experiencing severe chest pain, sudden or partial loss of motor function, altered mental status, signs of extreme hyperglycemia, or other life-threatening issues, should call 9-1-1, irrespective of the COVID-19 pandemic.
