Health care is proving vulnerable during the Coronavirus-induced recession.
Near the end of January, emergency departments across the country were nearing the end of the winter flu season and families were getting ready making plans for the upcoming Spring break. As an emergency physician, I was glad it was mild despite early concerns by the Centers for Disease Control and Prevention that 2019-2020 may be a bad flu season.
Even Dr. Anthony Fauci was quoted as saying in 2019 “The initial indicators indicate this is not going to be a good season — this is going to be a bad season,” I was ready for Spring to begin and put old man winter in the rear view mirror.
In late December/early January, I kept hearing about a “SARS-like virus,” which was being called “novel Coronavirus.” It was beginning to spread in Wuhan, China and there were concerns about a possible pandemic. The world had been through these coronavirus epidemic scares before in 2003 (SARS) and 2013 (MERS) and made it through unscathed. “Novel coronavirus” remained in the background for most emergency physicians…until it wasn’t in the background.
Beginning in mid-January, COVID-19 was spreading across Asia and into Europe. As cases were rising, countries were placing previously unheard of travel restrictions to help curb the spread. Cable networks began having 24/7 coverage on the spread of COVID-19. Fear of the unknown was palpable as healthcare providers around the world began preparing for what seemed like an apocalyptic event.
Politicians, hospital CEOs and news anchors threw around terms like PPE, N-95 and “surge” while on-the-ground emergency providers began preparing for an onslaught of patients that we thought would crush our emergency systems.
Hospital systems across the country prepared by developing plans for a pandemic emergency response, PPE conservation and surge capacity. On Feb. 26, the US had its’ first COVID case via local transmission and three days later, we had our first documented COVID-19 related death. By March 17, all 50 states had documented cases. Emergency medicine was ready to step up and take care of the onslaught we were all expecting…except it did not materialize as we had anticipated.
Most years, emergency departments patient volumes remain constant from January through late spring with a summer drop-off in volume beginning at the end of May. What we saw with the COVID pandemic was vastly different.
In the weeks following stay-at-home orders of various lengths issued by the governors of 43 states to curb the spread of the COVID, emergency rooms across the country noticed an unusual phenomenon — a sharp decline in patient visits. While there were focal spots of high volume due to COVID, most hospital systems across the country reported a volume drop as much as 50% in the emergency department.
The National Syndromic Surveillance Program (NSSP) found that the emergency department visits declined 42% during the early COVID-19 pandemic, from a mean of 2.1 million per week to 1.2 million per week. The steepest decreases were noted in persons aged ≤ 14, females and the Northeast portion of the country. 
The largest declines for adults were in visits for abdominal signs and symptoms, musculoskeletal pain, essential hypertension, nausea and vomiting, other specified upper respiratory infections, sprains and strains, nonspecific chest pain, and superficial injuries.
In the 2019 comparison period, 12% of all ED visits were in children aged ≤10 years old, compared with 6% during the early pandemic period. Among children aged ≤10 years, the largest declines were in visits for influenza (97% decrease), otitis media (85%), other specified upper respiratory conditions (84%), nausea and vomiting (84%), asthma (84%), viral infection (79%), respiratory signs and symptoms (78%), abdominal pain and other digestive or abdomen symptoms (78%) and fever (72%).1 The bread and butter of emergency medicine was pushed aside for COVID.
The reason for declining ER visits appeared mainly two-fold: strict public adherence to the governments’ stay-at-home directive and fear of contracting the potentially deadly virus. But the dramatic drop in overall ER visits is only part of the story as hospital admissions also have declined, partly because fewer patients are coming in through the ER and partly because of the ban on elective surgeries.
As a result, many hospitals laid off, furloughed or cut pay for affiliated physicians and staff. The U.S. Bureau of Labor Statistics reported that nationally, health-care employment declined by 43,000 positions in March.
Once considered a bulwark during economic downturns, health care is proving vulnerable during the coronavirus-induced recession, with spending down and significant job losses. More than 1.4 million jobs in the sector were lost in April, part of a historic economic decline that included 20.5 million fewer jobs and an unemployment rate reaching nearly 15 percent. As the healthcare industry was trying to brace the financial impact of COVID, and the massive disruption in the way care was provided, one question percolated in the minds of most emergency physician…would the patients return?
As we fast forward to June 2020, it appears the pandemic is here to stay for the time being. While there was a rebound in ED visits in May, the CDC noted the volume of visits remain significantly lower with a 26% decline in the last week of May 2020 compared with figures from a 2019.
After a brief respite in COVID cases in May, COVID has had a resurgence across the US since the Memorial Day national holiday. With a lift in the stay-at-home orders and a lift of the initial lockdowns in many states across the US, COVID cases have risen exponentially in many states in June. Additional factors cited for the rise in cases include the recent national protests and non-adherence to social distancing and wearing face masks.
Figure 3. Trends in Cumulative Number of COVID-19 Cases in the United States, Reported to CDC
Emergency departments across the country are seeing a resurgence of volume previously thought would take months to rebound. As of June 28, the CDC had not released any new data trends about emergency department volume trends in June 2020. However, anecdotal data in the six emergency departments we staff notes a rising trend of average daily visits since the end of April after a precipitous drop in volume from March and April.
Similarly to national trends, our emergency department volume dropped more than 53% in April, but has begun to trend back up in May and June. As the number of COVID cases continues to rise in Texas and in many places around the country, emergency department volumes are also trending up with not only COVID patients but also bread and butter of emergency medicine.
Figure 4. Comparing Trends in Average Daily Visits Across Six Emergency Departments From February to June in 2019 and 2020.
The striking decline in ED visits nationwide, most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public. The public 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. 
It is especially critical to reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction, stroke or other non-respiratory infections. If fear of the pandemic leads people to delay or avoid care, then the death rate will extend far beyond those directly infected by the virus. Time to treatment dictates the outcomes for people with heart attacks and strokes. These deaths may not be labeled COVID-19 deaths, but surely, they are collateral damage.
As patients stay away, heart attack and stroke teams, always poised to rush in and save lives, are mostly idle. This is not a phenomenon specific to the United States. Investigators from Spain reported a 40 percent reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit.
As volumes begin ramping up as we have seen in June, we are going to see more and more acute, exacerbations of chronic illnesses in the next few weeks. While the country has been able to maneuver care via telemedicine and virtual medicine for a few weeks, I am not sure the country could squeak by for multiple months using the same platform. For that reason alone, I believe we are going to gradually start seeing more active disease coming into the hospitals, specifically into our emergency departments in the coming weeks and months.
- Centers for Disease Control and Prevention. (2020, June 12). Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020. Morbidity and Mortality Weekly Reports. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e1.htm?s_cid=mm6923e1_w
- CDC COVID Data Tracker, CDC, June 29, 2020. https://www.cdc.gov/covid-data-tracker/#trends.
- Abelson, Reed. “ Hospitals Struggle to Restart Lucrative Elective Care After Coronavirus Shutdowns.” The New York Times, 21 May. 2020, https://www.nytimes.com/2020/05/09/health/hospitals-coronavirus-reopening.html
- Wood, Shelley. “The Mystery of the Missing STEMI’s During the COVDI Pandemic.” 02 April, 2020. https://www.tctmd.com/news/mystery-missing-stemis-during-covid-19-pandemic