Revista nº 815

Lacorzana J, et al. | Use of emergency department during COVID-19 pandemic 31 Actual Med.2022;107(815):27- 33 by taxes and does not involve co-payments for using the EDs. This universal health care system has evident benefits for the population but can imply a misuse of the system, particularly in the emergency room, where no appointment is needed to get medical attention (11–13). The current study sought to identify the possible influences of COVID pandemic on the pattern of use of the EDs, with special emphasis on the BHCS, trying to provide scientific evidence to help us better understand its effects on the health care system and allow us to develop better health care plans. Different authors (13,14) from countries with BHCS, such as Italy, reported a general reduction of referrals to the EDs during the first wave of the COVID pandemic; varying the decrease with respect to previous years from 34.4% to 46.3%. Our figures were consistent with them showed an overall reduction in EDs admission of 38.83% in 2020 compared to 2019. The influence of COVID on pediatrics attendance pattern to EDs showed engaging data as well. Different studies revealed a decreased in children attending from 27.11% to 88 % in 2020 compared to previous years reduction of 54.59%. Interestingly in our CH’s ED, there was a decreased in attendance to the EDs a week before the Spanish lockdown, possibly this can be explained because parents were the most sensible and foresighted due to the international context. Bellan et al.(13) and Ojetti et al.(14) revealed a rise in hospitalizations ratio from 2019 (16.9%) to 2020 (35.5%)(13) or from 2018 and 2019 (27.7% and 26.4%, respectively) to 2020 (42.9%)(14). Our hospitalizations ratio in patients attending the ED of the GH was overall higher than in the same period of the previous year and reached almost 51% around March 25-27 th 2020, in the NTH the higher ratio (27.3%) was reached on similar dates (March 22 th 2020). Therefore, these figures might suggest a greater severity of patients attended in the ED during the first wave of the COVID-19 pandemic (14). Concerning priorities, if we compare month on month in each year, changes in trend CH and NTH’s EDs were identified; while no notable changes were observed in GH’s ED. In the GH’s ED the priority 5 is the highest in all months (both years) but in the CH’s ED from May the highest priority changed. In the CH before May the highest priority was priority 3 (both years) but after May the most frequent priority was priority 3 in 2019 and 4 in 2020. In NTH’s ED the highest priority was priority 3 before March (both years), however, in the following months, the highest priority in 2019 is priority 3 but in 2020 is priority 5. This change in pattern of use continued until June. If we analyse our data in more depth, we can obtain more useful information. During March 2020, priorities 4 and 5 increased and priorities 1 and 2 remained stable in CH’s ED, while priority 3 decreased. This could be explained in part because urgent (priority 3) pediatric cases did not attend as usual because of the fear of contagion. Nevertheless, in April and May 2020 priority 2 increased significantly compared with the same months of 2019 (2.5% April 2019 vs 5% April 2020; 0.7% May 2019 vs 1.9% May 2020). A plausible explication for these changes might be that some of the urgent cases who did not attend in Mach, with non-resolved and even worse clinical pictures, decided to attend in April and May. These changes appeared to achieve a “normal” situation in June with the end of the de-escalation process (1.4% June 2019 vs 1.7% June 2020). In NTH’s ED, priority 2 and 5 increased in March 2020 at the expense of the decrease in urgent and standard cases (priority 3 and 4 respectively). Priorities 3 and 4 were usually patients with pathologies associated with minor (e.g. whiplash, muscular contracture, etc) and medium traffic accidents (not polytrauma); thus, they were reduced possibly by traffic closure. On the other hand, emergency care for serious cases was delayed, as can be seen in figures 2 and 3, possibly due to fear of COVID as previously mentioned. Other authors have reported less attendance of patients with emergency pathology such as stroke (13–15), heart attack and sepsis (13,14,16) in accordance with our results. In addition, the complicated situation of cohabitation and mental exhaustion in Lockdown caused a growth in psychiatric pathologies (self- harm) (17). McIntyre et al. (17) found that the rate of presentation with self-harm dropped by 35% in the first two months of the COVID-19 pandemic and rose by 104% in the following two months. If a period of economic instability follows as predicted, it is likely that this will further impact the mental health of the population, along with rates of self-harm and suicidal behaviours. Thus, it could be useful to investigate not only the long-term effect of COVID-19 but also the consequences of lockdown restrictions. If we re-analyze our result globally, there are a few facts that stand out. The overall reduction of admissions and hospitalization were 38.83% and 10.55%, respectively. Both drops should be alike, however, they were not; the reduction in the number of hospitalizations did not correlate directly with the decrease in admissions. Probably, changes in the pattern of use of EDs is the main cause for these differences. Moreover, these data lead us to discuss about the BHCS. This health care system has been criticized because, in normal conditions, people attend ED not only when they suffer from a severe health problem, but also as a way to get quick and free access to medical care, which constitutes a misuse of the system. Our data suggest that the theory about the misused of EDs could be true. Nonetheless, we have not been able to confirm this hypothesis with our data. To confirm this hypothesis, future prospective and randomized studies should be performed.