ED Visits; Abdominal CT Decline During Pandemic

Fewer patients are going to the emergency department during the COVID-19 pandemic, leading to a decline in abdominal CT scans and poorer patient prognoses, a new study shows.

In an article published on Aug. 20 in the Journal of the American College of Radiology, investigators from the University of Toronto and the University of Ottawa in Canada, discussed what they referred to as “collateral damage” from the pandemic – the patients who end up with worse outcomes because they delay coming into the emergency department for stomach pain.

In a head-to-head comparison of emergency department activity during a 4-week period in 2019 and 2020, the researchers identified a 46.7-percent drop in the net number of emergency department visits, as well as a 42-percent decline in the number of abdominal CT scans. The number of patients with complications and those who required surgery also rose significantly from year-to-year.

“This information has important public-health implications,” said the team led by Ciara M. O’Brien, assistant professor of abdominal imaging at the University of Toronto, “and highlights the need to educate patients to continue to present to hospitals services during such crises, or indeed, in a purported second wave arises.”

Delays in diagnosis and treatment can lead to surgical interventions or chemotherapy that could have been avoided, the team said. Paying attention to abdominal symptoms is also vital during the pandemic because COVID-19 is associated with abdominal manifestations in the bowel and liver.

To identify the differences before the cohorts of CT scans examined in this study, O’Brien’s team conducted a retrospective, observational study, looking at patients referred by the emergency department for abdominal CT scans from March 15 – April 15, 2019, and from March 15 – April 15, 2020. Overall, this included 1,155 patients – 733 from 2019 and 422 from 2020.

They examined the CT scans for abnormalities categorized into several groups, including gastrointestinal, genitourinary, hepatobiliary and pancreas, peritoneal, and malignancy. Among the gastrointestinal pathologies, they focused on inflammation, ischemia, bowel obstruction, diverticulitis, and appendicitis. And, complications included perforation, abscess formation, reactive inflammation of adjacent structures, aspiration, cardiac arrest, and first-time diagnosis of invasive cancer.

Based on their analysis, they discovered that while the number of requested CT scans fell, the number of those scans with positive findings jumped from 32.7 percent in 2019 to 50.5 percent in 2020. And, they also determined cases with complications rose from 7.9 percent to 19.7 percent, and population of patients who needed surgery ballooned from 26.3 percent to 47.6 percent.

Although the specifics are unclear of why the prognoses of these patients is worse during the pandemic, O’Brien’s team did have some ideas. It is possible that many postponed their trips to the emergency department in an effort to avoid potential COVID-19 exposure, presenting in worse condition when they finally do arrive. The increase in complicated appendicitis cases from 20 percent in 2019 to 39 percent in 2020 and the rise of bowel obstructions from 6 percent to 30 percent underscore that theory.

Being aware of these differences could be critical as the pandemic continues to linger, the team said, particularly if the virus begins to surge again.

“In the event of a second wave of COVID-19, patients need to be educated on when to present to the emergency departments for assessment. They should be informed of the measures in place throughout healthcare institutions to keep them safe from the spread of the virus,” the team wrote. “The onus is on the government, media, and healthcare institutions to publicize the measures undertaken to ensure patient safety during the pandemic and reduce anxiety associated with presenting to hospital when in need of any type of medical attention.”